Core Surgery Training - Level 2 visit report

 

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

Organisation under review: Royal Devon and Exeter NHS Foundation 

Placements reviewed: Core Surgery Training

Date of Review: 8th December 2017

 

BACKGROUND

Reason for Review

Feedback from ARCP, JCST survey, GMC NTS, Quality Panels

No. of Learners met

 7

No. of Supervisors/Mentors met                        

 

Other Staff members met

Management Teams: T&O, General Surgery

Duration of review

 1 day

Intelligence sources seen prior to review

ARCP outcomes

2017 GMC NTS results

JCST survey results

Quality Panel data

Log book data

Trainee written concerns/exception reports

Rotas

WBA completion by Consultant trainers and others

 

PANEL MEMBERS

Name Job Title
Martin Davis  Head of Quality, HEE
Esther McLarty TPD for Core Surgery
Lt.Col Michael Butler TPD for T&O
Jane Bunce Quality Manager, HEE
Kitty Heardman Lay Representative
Neil Squires Business and Operations Manager, HEE
Sophie Rose Quality Support Administrator

 

EXECUTIVE SUMMARY

A triggered visit was undertaken to respond to concerns raised about a number of placements in the Core Surgical Training Programme running within the Peninsula footprint. The placements raising concern were based in the Royal Devon and Exeter Hospital. The concerns were raised through the quality panel outcomes and individual trainee issues raised with the TPD. The concerns were primarily focussed around insufficient access to training opportunities to allow satisfactory progression of trainees.


The panel were pleased with the engagement of the Trust. There was a clear desire expressed by key individuals to ensure good quality training. They need support from the wider team. There was a common theme of service commitments impacting on the quantity of training available (primarily access to surgical intervention with appropriate supervision of their operating skills). Common themes were difficulty in recruiting to surgical posts leading to rota gaps and insufficient progress in service redesign (changing job roles and skill mix).


The Royal Devon and Exeter presented a plan for redesign of trainee surgical work patterns which if implemented should address many of the issues found.

The requirements and recommendations for each organisation are contained in the body of the report. The organisation is required to produce an action plan. The implementation of the action plan and the evidence for it addressing the concerns will be monitored by HEE.


An urgent work schedule (timetable) for each Core Surgical Trainee is required immediately, in line with the new junior doctors contract and compliant with the Quality Indicators for core Surgical training, and should be submitted to HEE by 28th February 2018.  The adherence and implementation of the work schedule requires close monitoring by their Assigned Educational Supervisor with concerns raised to the College Tutor and TPD where necessary.  The posts will be formally reviewed at the Quality Panel in July 2018

REPORT SIGN OFF

Outcome report completed by (name) Jane Bunce / Dr Martin Davis
Chair's signature Dr Martin Davis
Date signed 15th February 2018
 
HEE authorised signature Dr Martin Davis 
Date signed 15th February 2018
Date submitted to organisation 15th February 2018

 

 ORGANISATION STAFF TO WHOM REPORT IS TO BE SENT

Job title Name
Director of Medical Education Chris Mulgrew

 

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 action? Fed back to the T&O trainers who were aware of risks and were already working towards an appropriate solution.
Brief Summary of Concern A potential patient safety issue was raised by trainees that patients can leave theatre without their drug chart having been written up.

The department is in the process of attempting to change its culture so that the Anaesthetists will complete drug charts or have this form part of the pre-op pack. We  suggest that this is formalised in both trusts as part of the WHO checklist

 

EDUCATIONAL REQUIREMENTS

Recommendations are a proposal as to the best course of action.

 

Were any requirements to improve education identified? YES

 

Related Domain(s) and Standard(s) 

Theme 1 and 3

Summary of findings

In Exeter a significant issue was found in Upper GI with trainees having exposure to a limited case mix.  The panel noted limited progression of trainee’s skills as a consequence of the limited case mix and a requirement to continue to undertake the same procedure already learnt e.g. excessive camera holding.

Required action

To ensure trainees are exposed to a wider case mix.
Ensure progression of trainee’s competence in line with their PDP. This post is unsuitable for a 6 month CST placement with the current case mix. If this cannot be rectified then the trainees will need to be rotated to other general surgical subspecialties.

 

Related Domain(s) & Standard(s)

Theme 1 and 3

Summary of findings         

In Exeter CSTs are being required to cover F1s in situations where with planning this would be avoidable, or tasks could be completed by other healthcare professionals.

Required action

CSTs should only have to cover Foundation doctors duties when the situation is unavoidable e.g. sickness. Ensure adequate provision of Allied Healthcare Professionals to cover service commitment

 

Related Domain(s) & Standard(s)

 Theme 1 and 3

Summary of findings

Attendance at elective sessions is not prescribed in trainees work schedules. This is leading to lack of clarity about their role and does not make visible missed training opportunities and compliance with quality indicators difficult to assess.

Required action

Detailed work schedules (timetables) for all CST to be produced that are consistent with CST Quality Indicators.  If trainees are not able to get to assigned theatre sessions etc. trainees should exception report and a subsequent discussion held between the trainee and their educational supervisor to identify alternate training sessions.

 

Related Domain(s) & Standard(s)

Theme 1 and 3

Summary of findings

There have been multiple instances at Exeter where trainees have failed ARCPs due to lack of exposure to consultant led training opportunities and AES not having checked portfolios for progress.

Required action

All AESs should maintain a regular review of a trainee’s progression against their PDP and if this is failing a remedial package put in place and the issue raised with the college tutor. College Tutors are expected to maintain oversight of Core Surgical trainees progress towards completing their global objectives and raise concerns with trainees, trainers and the TPD so issues are resolved prior to ARCP.

 

Related Domain(s) & Standard(s)

Theme 1 and 3

Summary of findings

The rota for most CSTs does not allow adequate time and opportunity for training 

Required action

The rotas for CST both in T&O and General Surgery presented in the Trust’s review of CST need implementation with the addition of detailed work schedules that conform to the CST Quality Indicators. Clarity is required about when annual and study leave can be taken and how this affect overall exposure to consultant led training sessions.

 

 

 EDUCATIONAL RECOMMENDATIONS

Related Domain(s) & Standard(s)

Theme 1

Summary of findings

Recognise the need to look at alternative workforce models to substitute for gaps in doctor rotas and that this needs to be followed through to ensure a sustainable, effective and achievable action plan is in place.

All departments need to ensure adequate time and opportunity is available to allow CST QI’s to be met and the required Work Place Based Assessments to be completed (particularly Consultant validated WBA’s)

 

 

Summary of discussions with groups

The Trust had produced a report in preparation for the visit which outlined current challenges and some proposed solutions.  This is included as appendix 3.  The panel acknowledged at the end of the visit that if the actions included in the document are implemented it will make a significant difference to the concerns raised which have prompted the concerns visit. However individual work schedules are still awaited.

 

TRAINEES

The panel met with 7 trainees with experiences from different posts within the programme.

 

Orthopaedics

Training opportunities and teaching

The Orthopaedic trainees reported that training opportunities can be neglected at the expense of undertaking necessary service duties on the ward and on-call.  This limits the opportunities to be involved in operating theatre work either emergency or elective. There is an inappropriate balance between training and service needs.  They acknowledged that the consultants are very willing to teach but they don’t often get the opportunity to do so. Trainee are not provided with work schedules that full fill the CST QI’s and new junior doctors contract requirements

The trainees understood that there is difficulty recruiting suitable individuals to the department.  They described that the rota is gradually becoming increasingly difficult to staff as unfilled posts increase.  Jobs such as venepuncture, inserting cannulas and re-writing drug charts are taking time to complete and restricting training opportunities when all could be undertaken by other varieties of staff if available and appointed.  The panel asked the group if they had been involved in discussions regarding a revised rota and they confirmed that they had and that they believed the newly proposed rota, within the paper presented by the Trust could work if implemented.

The trainees reported that there is a trauma meeting every morning.  The quality and value of this from the perspective of core surgical trainee is variable and consultant led dependant. There is scope for the educational lead in the department to formalise the educational components of this meeting and use some time to complete consultant work place based assessments that are required in the CST curriculum.

Regional teaching is organised for the CST’s. It can be difficult to attend if on-call or following nights which with gaps in the rota occurs more frequently. These are mandatory for CST’s (unless enabled to attend HST days following exam success) and dates are available months in advance on the School of Surgery pages of the Peninsula Deanery website. College tutors are also informed of these dates.

The registrars in the emergency department were reported as being good at getting the orthopaedic CSTs involved in procedures such as manipulation but this does vary dependent upon which registrar in the department they are working with.

Elective theatre opportunities were discussed. The CST trainees felt that Fellows and Registrars had more opportunity to attend and be involved with these as they had dedicated theatre time within their timetables for this.  The CSTs are first on call to the ward, this has the consequence that if they do get to theatre, they can get called away, making it difficult to commit to a supervisor to being taught through a specific case or list. CST’s should have equal access to protected training opportunities in theatre and clinics which should be detailed in their work schedules and consistent with the JCST QI’s for CST.

Quality Indicators

The trainees were asked if their experience meets the QIs required by the JCST and GMC to enable an approved training programme:

Opportunity to attend at least one fracture clinic a week Variable experience reported
Attendance at 3 theatre sessions a week – 2 trauma and 1 elective

Trauma – variable experience

No elective theatre experience
Attendance at one consultant ward round per week CSTs do a ward round if on-call but not generally with a Consultant.  CSTs tend to do a ward round on their own with registrars and consultants doing a round at another time

Trainees were asked what one thing they would change: Scheduled time off the ward to attend theatre.  In order to achieve this it was felt that 2 F1s or nurse practitioners would be required to support the ward.  It was noted that a clinical secretary is now helping with the electronic discharge which was viewed as a positive improvement.

 

Patient safety

A potential patient safety issue was raised in that patients can leave theatre without their drug chart having been written up.

 

General Surgery

Rota

The general surgery rota was reported as the main issue for CSTs.  Trainees understood that this had been reviewed and a new rota had been written but yet implemented.  It is a twelve week rolling rota which will allow for more continuity which had previously been a problem.

The rota is expected to be implemented in April.  It was understood that its introduction could not be before then due to pre-existing commitments such as planned annual leave, study leave for exams etc.

The current rota was described as haphazard with no formal timetabling for CSTs to attend theatre.  CT2s and F1 trainees are not treated as being different in terms of experience and training needs on the current rota. Work schedules are not provided to trainees leading to ad-hoc attendance at consultant led training opportunities, and lack of ability to exception report when these scheduled events do not occur due to service issues.

 

Quality Indicators

Trainees reported that their posts in general surgery offered them the opportunity to meet the majority of Quality Indicators.  Access to emergency cases in colorectal and upper GI was variable.  Vascular was reported as being adequately staffed and therefore able to meeting all QIs.  Breast placement was reported as meeting the Qis. The experience in both vascular and breast was reported by the trainees as being very good.  Colorectal was reported as being very good, with improvement since changes had been introduced in August.  Additional registrars had been allocated to the rota which means that CSTs have become more available to attend theatre and clinics.  Trainees felt the current improvements were sustainable.

In Upper GI consultants were reported as gradually letting CST do more but there is a lack of junior cover which can inhibit this.  The first 4 months of the rota is better staffed but as F1s start to take leave towards the end of a placement, rotas can become more of a problem.  In some instances busy lists were seen as a cause of limited opportunities.  A lack of progression was also reported and trainees said that different consultants have different expectations of their competencies.  Whilst trainees can attend one theatre list a week, the lack of progression relates persistence of a specific task for example to an excess of camera holding with one particular consultant.  In other instances a consultant has developed a PDP with a trainee and shown a commitment to working towards that.  The majority of the caseload/ trainee log book is laparoscopic cholecystectomy which whilst valuable in CST and should provide only a small part of a broad based surgical experience at this level. These posts would appear better suited to an HST with a commitment to this type of surgery and are unsuitable for CST.

At the time of the visit there was no Urology trainee present.  Previous evidence has been mixed and staff shortages had been a problem with no specific timetable to attend theatre and clinics. The degree of participation in the general surgical on -call rota has stopped trainees full filling their training needs, but Miss Angela Cottrell, Foundation TPD and Consultant Urological Surgeon assured the panel that with the introduction of the new general surgery core rota the Urology training needs could be met and timetabled. It is noted that general surgical experience does not count towards the training criteria for a specific Urology post.

In summary, discussions indicated a lack of trainee numbers; a need for closer working with an AES to achieve an agreed PDP; a schedule (timetable) which includes theatre and clinic time would set expectations that trainees would be present in these sessions and when not discussion can take place for the reasons for this. The case mix in upper GI surgery is limited which is restricting the trainees training opportunities. Regular monitoring of trainees progress and log books by the College Tutor could ensure Quality Indicators are achieved and lead to early remedial intervention.

 

TRAINERS

Orthopaedics

The panel met with 2 Orthopaedic trainers and 3 management team members.

 

Rota

The management team and trainers felt that the new rota will meet training requirements but the challenge is ensuring that the needs of the service are met.  Arrangements have been put in place for a ward based clinical secretary to help with some administrative tasks.  A trauma nurse practitioner is currently being trained and after Christmas, will be available to work on the ward at Physician Associate level (2 more years of training to become fully trained and able to prescribe).  Pharmacists also form part of ward staff and an advert for a Peri-operative Physician aims to make the elective aspect of Orthopaedics able to function without dependence on a surgical doctor being present.  The finance for this initiative has been agreed, implementation will depend on the ability to recruit to the posts.  Allowing the trainees to work outside of the ward is seen as key to improving the CSTs training experience.

 

Patient Safety

The patient safety issue raised by trainees was discussed.  The department is in the process of attempting to change its culture so that the Anaesthetists will complete drug charts or have this form part of the pre-operative pack.

 

Supervision

Trainers confirmed that they set objectives for placements, fill out the ISCP and check progress regularly.  All colleagues are aware of the requirement to complete WBA and this has improved recently.  Trainees are directed towards consultants who are more educationally focussed.

Educational Supervision is recognised in job plans at 0.25PA / week. 

Trainers described the desire to introduce discussion at the end of each trauma list in the same way as some other centres.

 

Teaching

It was noted that the new rota will need to be adjusted to allow attendance at monthly Monday regional training days.

 

General Surgery

The panel met with 8 trainers and management team members.

 

Supervision

It was recognised that for the first time ARCP pass rates had been poor and rota issues have limited access to training opportunities with these problems being reported through quality panels, GMC NTS and the JCST survey.  It was noted that these problems had not been flagged in advance of ARCPs so that remediation packages for trainees could be considered. A system to monitor trainees progress and readiness for ARCP should be formalised to include AES review and the overarching involvement of the College Tutor to ensure global objectives are met.

 

Rota

The trainers explained that trainees will be supernumerary when ward based on the new rota which is due to be introduced from April2018. It was confirmed that the new rota redistributes existing staff numbers and isn’t dependant on further recruitment.

Concerns were raised by the vascular team that if trainees were to be more closely supported in clinics, then numbers seen would need reducing. This could have implications to patient access and cost to the Trust.  The requirement for CST’s to have exposure to clinics is not new and is an essential part of their learning experience.

Urology and Vascular confirmed that the new rota will mean that when not on-call, all trainees will have access to the required elective training opportunities in clinic or theatre.

 

Training opportunities

The panel expressed concerns regarding the amount of times trainees are required to undertake repetitive tasks in theatre that was not advancing their training in upper GI such as camera holding. The panel were concerned about the upper GI trainer’s knowledge of the educational needs of core surgical trainees.

The trainers recognised the need to be more prescriptive in terms of where trainees are placed to ensure they get to theatre and clinics.

The trainers were signposted to the report Improving Surgical Training document which outlines what posts need to look like and what the minimum rota standards should be: https://www.rcseng.ac.uk/news-and-events/news/archive/pilot-sites-announced-for-new-surgical-training-programme/

 

Summary – Exeter

  • The visiting team were pleased with the engagement from the Trust in acknowledging and providing potential solutions to the problems highlighted.
  • The panel had concerns about the restrictive case mix available in Upper GI placement and the knowledge of the trainers with respect to the training needs of this group of trainees. This post is unsuitable for CST in its present form and significant breadth needs to be added to this post for it to become suitable. Concerns were also raised by the panel about the understanding of the CST programme from the trainers in this department. Alternate CS and AES should be sought for these posts.
  • Ensure timely and regular review of a trainees progress against their PDP is undertaken for all trainees.
  • The need for CSTs to act down to cover needs to be limited to scenarios that couldn’t be predicted e.g. sickness.
  • A detailed work schedule (timetable) for all CST trainees is needed to ensure they are getting exposure to the required clinics, theatre sessions and where not they are able to exception report to highlight this to the department and DME.
  • The Trust recognises the need to continue to be creative about its future workforce acknowledging that training posts and therefore recruitment to surgical posts in the future will not improve.

Date of report: 19th January 2018

Author: Jane Bunce / Martin Davis

Job Title: Quality Manager / Head of Quality