Community Paediatrics - Level 2 visit report

 

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

Organisation under review: University Hospitals Plymouth NHS Trust

Placements reviewed: Community Paediatrics

Date of Review: 10th December 2018

 

BACKGROUND

Reason for Review

HEE was made aware of problems within Community Paediatrics by the Head of School, following the 2018 Quality Panel where it was reported that there was a:

  • Lack of clinical supervision and opportunities for trainees to discuss complex patients seen in their daily clinical work.  Trainees can be the only doctor in the CDC. When this occurs the escalation process for clinical concerns is unclear with trainees resorting to calling the General Paediatrician in Derriford for advice.
  • Lack of formal teaching at CDC compounded by clinic timetabling making it difficult for trainees to attend organised teaching sessions at Derriford.
  • Problem in getting WPBA's completed as mandated by the curriculum they are working to.
Concern about patient safety due to a limited induction and expectations of ability which can exceed their current competence. 

No. of Learners met

 2

No. of Supervisors/Mentors met

 1

Other Staff members met

Service Director and Clinical Tutor

Duration of review

3 hours

Intelligence sources seen prior to review

Draft 2018 Quality Panel Report

 

PANEL MEMBERS

Name Job Title
Dr Martin Davis Head of Quality, HEE (Chair)
Dr Kumar Yadlapalli Head of School for Paediatrics
Dr Eleanor Thomas Community Paediatrician, Royal Devon and Exeter NHS Trust
Graham Stoate Lay Representative
Jane Bunce Quality Manager, HEE

 

EXECUTIVE SUMMARY

HEE was made aware of problems within Community Paediatrics by the Head of School, following the 2018 Quality Panel.  Following a meeting with trainees, the Departmental Supervisor, College Tutor, and Service Director it was clear to the panel that issues are a consequence of shortage of senior staff within the department (illness, retirement, and resignation).  At the time of the visit, there were indications that staffing levels may improve in early 2019. This however was dependent upon a return to work from ill health and successful recruitment of a locum due to start in March of 2019. The visiting panel agreed several requirements which need implementing, these are:

  • An appropriate balance of service and training
  • Ensuring that all patients have a named consultant responsible for their care who is actively working in the department
  • Clarity about the supervisory arrangements for discussing those patients that the trainee needs assistance with.
  • Clarity and engagement with the roles of Educational and Clinical Supervisors. This needs to be more widely distributed within the department. Whilst the Clinical Supervisor must come from within the department the Educational Supervisor role could come from the wider Paediatric department
  • Ensuring that trainees have the opportunity and time to undertake WPBAs
  • Ensure the case mix within a clinic provides opportunities for learning and isn’t solely driven by service needs

Ensure induction is fit for purpose and recognises the different levels of competence of trainees who are placed in the department 

REPORT SIGN OFF

Outcome report completed by (name) Jane Bunce / Dr Martin Davis
Chair's signature Dr Martin Davis
Date signed  11.2.19
 
HEE authorised signature Dr Martin Davis
Date signed  11.2.19
Date submitted to organisation  11.2.19

 

 ORGANISATION STAFF TO WHOM REPORT IS TO BE SENT

Job title Name
Matthew Bowles Director of Medical Education
Simon Cortman Service Director
Myooren Wimalendra Clinical Tutor

 

Risk Scores (1-25; see Appendix 2 for breakdown)

Scores prior to review 4x5=20
Proposed scores following review 4x5=20

 

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?  NO

 

EDUCATIONAL REQUIREMENTS

Related Domain(s) & Standards 1, 3 & 5
Required action 1. The balance of service versus training needs to be addressed by the Trust/Department.  This includes:
  • Finding time for WPBAs
  • Improving case mix variety seen by trainees in clinic
  • Protected local departmental teaching time
  • Protected time to discuss patient cases seen in clinic in a timeframe that doesn’t compromise patient care

 

Related Domain(s) & Standards 1, 2 & 3
Required action

2. Ensure that all patients have a named consultant responsible for their care who is actively working in the department.

 

Related Domain(s) & Standards 1, 3 & 4
Required action 3. Educational Supervision within the department should be more visible and engaged with the trainee.  The ES could be a Paediatrician based in the main department, the CS should be department based

 

Related Domain(s) & Standards 3
Required action 4. Induction must be timely and fit the needs of trainees with varing degrees of previous exposure to the specialty

  

Summary of discussions with groups

Meeting with trainees

The panel met with 2 trainees, both of whom are less than full time.  The 2 trainees job share; currently one is an ST5 (Core trainee) and the other is an ST6 (specialising in community paediatrics).

The trainees reported that the department is understaffed.  There is a willingness to train and teach, but there is not enough time to allow this to happen.  Staff within the department were described as approachable. Morale is described as very low.

The visiting panel understood that when the department is fully staffed, there are 5 Paediatric Consultants (all less than full time); however, 3 are currently not at work for various reasons and the remaining 2 work part-time.  One of those absent at the time of the visit was due to return to work in January and 1 locum Consultant was due to commence in March (previously a trainee).  There are 4 staff grade doctors who were described as very helpful but the trainees were unsure if they are trained as supervisors.

After a few weeks in post, the trainees start to run their own clinics.  They reported that they do discuss each clinic but immediate supervision is not always available and because of consultant work patterns contact can be difficult.  Discussions can take place 2-3 days after a clinic and they only discuss the most pressing cases. There isn’t sufficient time to discuss cases for the purpose of enhancing their learning. There is often insufficient time for WPBAs and observation in clinics.  The staff grades were willing to help with WPBAs but their availability is limited.

The panel were informed that there is always another doctor in the building if there is an emergency that requires additional medical assistance.

MDTs for safeguarding issues take place at the main hospital site.

One of the trainees reported that they were trying to fulfil their training requirements in other ways i.e. outside of the department.  One of the trainees reported undertaking these activities in her own time.  At the time of the visit there was a Child Health Day coming up which they hoped to attend.  Both trainees felt reasonably confident about meeting the requirements of their ARCP; provided they can meet their competences in other ways.

The trainees are part of the General Paediatrics on-call rota.

The panel heard that the trainees conduct the clinics for the Consultant who has been off on long-term sick.  The clinics are run in that Consultants name. 

Managers were described as inflexible when trying to accommodate training needs. The work load within the department is high and it was reported that the post feels like a service job with little educational input.  There are numerous telephone queries that trainees must try to problem solve relating to patients whom they have little knowledge of.  There can be complex cases where there is a need for the trainees to discuss with someone more senior, but finding time to do this is an issue.

Induction was reported as requiring improvement. Trainees are exposed to areas of clinical practice with little knowledge of the patient’s problems

 

Trainees reported that they would like:

  • More protected time to discuss patients after clinics
  • Time for WPBAs
  • 1:1 specific teaching
  • 3 weekly clinics
  • Not to do direct clinical care on Monday’s when there is currently no Consultant presence

Both trainees said they would be interested in a QI project to develop induction.

 

In summary:

  • The department is under pressure due to reduced senior staffing
  • The post is service driven, with training needs not considered
  • Trainees feel that seeing some patients is outside of their competence to provide appropriate management plans
  • There is no protected time to discuss cases with supervisor or to complete WPBAs
  • Induction requires improvement
  • There is no protected local departmental teaching time
  • Trainees both have a CS/ES – the same Consultant for both
  • The Trust must ensure that there is protected time within consultants’ job plans for supervision

 

Meeting with Community Paediatric Consultant, ES/CS

The Consultant who met with the panel confirmed that the department should be staffed with 5 consultants but there were currently 2; 1 is off sick; 1 is on long-term sick; and 1 has left.  One Consultant was due to return in January and 1 is due to join from March for 3 days a week.  It was confirmed that morale is challenging within the department.

Up until the summer it was reported that training versus service balance was ‘pretty good’ and whilst the current situation is not ideal, the best is achieved within current constraints.  It was confirmed that there is time within the Consultant’s job plan for training (0.25 PAs).  The panel suggested that the supervisory burden could be shared more widely across the department to reduce pressure on the 1 named Consultant.  It was agreed that this could be possible.

The Consultant told the panel that she does sit down with trainees to complete WPBAs but the opportunities to do this vary due to time. 

It was confirmed that trainees are conducting clinics in the name of the Consultant who has been off-sick.  This was recognised as a problem but it was reported that it can be difficult to get admin to change their way of doing things.

There is an ambition for trainees to get a wider variety of clinics.  Currently clinics are biased towards ADHD and Autism as that is the absent Consultant’s workload.  More 1:1 supervisory sessions and dedicated teaching time would also be welcomed when there is less time pressure.  The Consultant met was reasonably optimistic that the Department will improve from the beginning of 2019 once the additional/returning staff commence.

There is an opportunity for trainees to sit in joint clinics for 2 weeks.  Trainees never have more than 4 patients in a clinic, although this can vary for more senior trainees.  Consultants will see 6.

 

Meeting with Service Director and Clinical Tutor

The Service Director confirmed that:

  • There have been short-term staffing issues with
    • 1 consultant due to return after Christmas
    • 1 new consultant due to commence in March
  • The Business Manager had been approached and asked to ensure a diversity of cases was available for trainees
  • The first hour of clinics could be set aside for trainee/supervisor clinic discussion
  • It is feasible to rotate trainees in to attend Safeguarding Clinics

The Clinical Tutor confirmed that he would be happy to meet with trainees and MD/YK asked that he keep an eye on trainee portfolios to ensure himself that no issues would arise at ARCP.

 

Final feedback from panel on day of visit to DME

  • It was clear that issues had been caused due to a shortage of staff within the Community Paediatrics Department
  • There is currently no service/training balance and this needs to change rapidly
  • The Department must ensure that trainees are not seeing patients whose named consultant is not currently working in the department
  • Educational Supervision within the department should take a hands-on approach and could be spread amongst the department.  ES could be based in the main paediatric department, with CS being present within the department
  • Time for WPBA must be found
  • The case mix variety must be addressed
  • Induction must improve and this could be achieved through a QI project instigated by trainees

 

 

Date of report: 9th January 2019

Author: Jane Bunce/Dr Martin Davis

Job Title: Quality Manager / Head of Quality