F2 Oncology and F2 Cardiology - Level 2 visit report

 

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

Organisation under review: Royal Cornwall Hospitals NHS Trust

Placements reviewed: F2 Oncology and F2 Cardiology

Date of Review: 4th July 2019

 

BACKGROUND

Reason for Review

Primarily due to concerns raised through the Quality Panel process.

No. of Learners met

 6

No. of Supervisors/Mentors met

 3

Other Staff members met

 3 management teams

Duration of review

 3hrs

Intelligence sources seen prior to review

2018 Quality Panel Report, GMC NTS data and previous Triggered Review Report for Oncology held in 2017

 

PANEL MEMBERS

 

Name Job Title
Dr Martin Davis Head of Quality, HEE (Chair)
Dr Linda Simpson GP Associate Dean, HEE-SW
Ms Kitty Heardman Lay Representative
Ms Trudi Geach Foundation School Manager
Ms Jane Bunce Quality Lead, HEE

 

EXECUTIVE SUMMARY

HEESW reviewed the training environment for Year 2 Foundation doctors in Oncology and Cardiology placements following concerns raised through the Quality Panel process. The Foundation Quality Panel had graded the F2 posts in these specialties as requiring improvement 3 years in succession. The concerns were raised in the areas of Clinical Supervision, Workload and Induction.

The panel reviewed the Quality panel data, GMC NTS feedback and received face to face feedback from a sample of recent trainees in the department, their supervisors and managers of the specialties.

All the individuals seen gave honest and constructive feedback to the panel. Both specialties have the potential to provide an excellent training environment for Foundation trainees. In both specialties the trainees felt supported and appreciated the feedback they receive in the placement.

There were a number of areas where the panel felt that changes would enhance the training environment and improve the experience for patients. These are highlighted in the findings and conclusion section of the report.

HEESW will ask for an update on the actions relating to these requirements and recommendations in 3 months’ time.

 

REPORT SIGN OFF

Outcome report completed by (name) Jane Bunce / Dr Martin Davis
Chair's signature Dr Martin Davis
Date signed 9/10/2019
 
HEE authorised signature Dr Martin Davis
Date signed 9/10/2019
Date submitted to organisation 9/10/2019

 

 ORGANISATION STAFF TO WHOM REPORT IS TO BE SENT

Job title Name
Dr Chris Williams Director of Medical Education, Royal Cornwall Hospitals NHS Trust
Dr Grant Stewart Consultant Oncologist
Dr Sen Devadathan Consultant Cardiologist
Dr Alistair Slade Consultant Cardiologist
Dr Arun Dhanasakeran Consultant Cardiologist
Sidwell Lawler General Manager, Specialty Medicine
Louise Hunt Service Lead for Haematology

Risk Scores

Scores prior to review 4 x 5 = 20
Proposed scores following review 3 x 5 = 15 (Oncology)
3 x 4 = 12 (Cardiology)

 

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?

 Dr Chris Williams
Brief summary of concern:

Oncology:

  1. F2 Trainees are prescribing for patients receiving treatment the following day (they are not prescribing chemotherapy) that they have not met.  They rely on written instructions, which some trainees reported can contain errors and do not always have contemporaneous clinical context.  Some near misses were reported to the visiting team. These had not been recorded on the Trust’s Datix system  Trainees should report any future occurrences through the Datix system and review of these reports will occur.
  2. The panel heard that patients can be discharged from hospital without having had a consultant review. This can lead to a lack of a definitive care plan guiding their ongoing treatment.
  3. Trainees reported being asked to prescribe opiates for patients attending the Headland Unit as day cases. These prescriptions are being issued without the ability to cross reference other opiate prescriptions the patients may have had issued from other healthcare professionals caring for them. This has the potential to contribute to opiate abuse but equally the trainees recognise the need to alleviate the patients pain appropriately.

 

EDUCATIONAL REQUIREMENTS 

 

Related Domain(s) & Standard(s) 1, 2, 3 & 4
Summary of findings

Oncology:

  1. It was recognised that over the past 12 months there has been an improvement in the educational support given to the trainees in the department. This is attributable to the input of Dr Stewart. Dr Stewart is also clinical lead to the department. The panel recognised the improvements made and is keen to see these embedded, however it is important that over reliance on one individual does not occur and the department sees these issues as a collective responsibility.
  2. The Department should enforce a stop to 9am clinic appointments to ensure that the board round implemented can occur as planned each morning. This will enhance patient care as an in-patient and improve efficiency of services.
  3. Time inappropriate tasks being requested by nurses on Headland for F2 doctors to undertake should be reviewed.

 

Cardiology:

 

  1. The Trust should review its process of allocating and relocating trainee doctors during times of increased clinical demand. The present system does not seem to recognise clinical priority and trainees workload.  Decision making to move trainees should be transparent and regular reports produced so that clinical managers can review decisions made.
    Trainees should be encouraged to raise exception reports when appropriate.
  2. Department should review the skill mix, particularly for CIU, and consider if job roles other than medical trained individuals could undertake some of the tasks the F2 Doctors currently do.

 

SUMMARY OF DISCUSSIONS

CARDIOLOGY TRAINEES

Trainees within Cardiology spend roughly half of their placement time on Roskear and half on CIU.  Time can also be spent on CCU.  The trainees spoken to described the placement as hectic, due to rota gaps.  It was recognised by trainees that the consultants are very busy.

 

When on CIU, trainees tend to be by themselves.  There are a lot of patients, and whilst they are mostly clinically stable, if one becomes acutely unwell the time to achieve the other tasks is not there.  Most of the tasks on CIU are straightforward, the volume is the challenge.  There is a particular pressure to complete TTOs to facilitate bed flow.  It is often necessary to stay late to complete all tasks. Exception reports have been raised in relation to this.  A consultant ward round occurs but is brief due to workload pressure of consultants.  Trainees felt that many of the tasks undertaken on CIU could be done by staff without a medical qualification.

 

On Roskear, there should be 3 trainee doctors covering the 28 beds.  Generally there are 2 trainees as 1 is often rota’d elsewhere or on leave.  It was described as a ‘hard job’, leaving trainees ‘drained’.

 

Trainees told the panel that the department is keen to teach.  There is opportunity to do an audit. Friday lunchtime teaching has become less regular and tends to be F2s presenting to each other.  Trainees would like more learning opportunity to go to the Cath Lab.

 

The trainees met said that the job would be manageable clinically and educationally valued if the allocated complement of trainees were working the majority of the time.  The placement would be improved by having the opportunity to go to clinic and experience the Cath Lab. Current workload pressures don’t allow this.

 

ONCOLOGY TRAINEES

Trainees in Oncology work on an 18-bed in-patient ward and in the Headland Day Unit, where patients receive chemotherapy treatment. 

 

Trainees told the panel that there are adequate learning opportunities when there is a full cohort on the rota.  Problems are created when there is no GP trainee in post which creates a barrier for them getting in to clinic.  The appointment of Clinical Fellows has reduced workload pressure.

 

The panel heard that Dr Stewart has implemented a new teaching programme.  He has also instigated a new process whereby the nurses review details of patients coming in for chemotherapy and rather than referring to an F2, they escalate as necessary to the Registrar.  The Registrar cover has also made it easier for F2s to gain advice. Dr Stewart has revised the induction process.

 

The consultant of the week arrangement was described as working better and a consultant now attends the daily board round approximately 70% of the time (due to workload and clinic pressure/timings).  The consultant of the week will not see another consultant’s patients but may give general oncological advice, rather than specialist, if necessary.  Trainees feel they miss out when the board round doesn’t occur.

 

Another recent improvement noted was the good Registrar cover and introduction of a Clinical Fellow.  Both regularly check on the F2s and if they are called, they will respond.

 

If someone is on leave, the job can become very busy.  On the ward there tends to be around 17 patients who have complex needs and are all clinically unwell.  F2s normally complete a sole ward round as well as having responsibility for all the jobs arising from this.  There is a consultant ward round at the weekend and trainees described scenarios whereby patients complete an in-patient stay without having seen a consultant.  This was highlighted as a potential patient safety issue.

 

Trainees in the initial cohort of 18/19 said there was a regular need to exception report (although they were encouraged not to do so); the most recent cohort reported an improving picture.

 

Another potential patient safety issue was highlighted.  The day before patients are due to receive treatment, F2s have to prescribe for patients they have never met (they do not prescribe chemo).  They rely on written instructions, which some trainees reported can contain errors and do not always have contemporaneous clinical context.

 

F2s described being called by nursing staff to attend to ‘emergency’ issues with patients on Headland Unit.  Trainees described these calls as not always being necessary in that they could be minor issues or problems that did not require input at that point in time.

 

F2s described the need for additional support in order to hold bad news conversations.

 

Trainees reported being asked to prescribe opiates for patients attending the Headland Unit as day cases. These prescriptions are being issued without the ability to cross reference other opiate prescriptions the patients may have had issued from other healthcare professionals caring for them. This has the potential to contribute to opiate abuse but equally the trainees recognise the need to alleviate the patients pain appropriately.

 

ONCOLOGY TRAINERS AND MANAGEMENT

Dr Grant Stewart joined the Oncology Department in February 2018.  Changes made since he commenced his involvement in education since summer 2018 have included:

  • Removal of acute oncology from the F2 job role as this took them away from the base unit
  • Introduction of an Education Faculty Meeting – a copy of the agenda and minutes from the October/January/June meetings were provided
  • Introduction of a Friday afternoon handover
  • A new induction process – a copy was provided for the panel
  • New formal teaching programme
  • Daily board round
  • Increased support/training around breaking bad news

 

Current trainee staffing levels include 2 x ST3 doctors and 2 Clinical Fellowes, plus the F2.  The consultant body is now fully staffed.

 

There were 8 or 9 Exception Reports in the first placement; none in the second; and they were back up to 3 for the current period.  Dr Stewart’s opinion is that the rise in exception reports is due to having a part-time GP trainee which creates a gap in the rota.

 

Dr Stewart commented that it would be a preference to substitute the GP trainee with an additional F2.  This is due to the unpredictability of a GP trainee being allocated to the department.  The Department would also like more training numbers if that was a possibility.

 

Dr Stewart explained that the board round doesn’t always happen due to the way in which the clinics are organised, workload pressure, clinical priorities.  Clinic shouldn’t start until 10am but occasionally appointments appear to be booked in from 9am.

 

CARDIOLOGY TRAINERS

The trainers explained that the department should have 5 trainees at Foundation/GP/CMT level.  It was confirmed that a consultant is always available on Roskear, CCU and CIU and the consultants now consist of 10 substantive staff.  Patients on CCU get priority which can cause delays to CIU and this is what causes the exception reporting.

 

The trainers present believed that the number of procedures conducted at Royal Cornwall Hospital are at the root of the problem – more procedures are carried out than at the tertiary centre which has 4.5 more SpRs.

 

It was suggested by the panel that discharge summaries could be completed by non-medical staff.  Cardiology in Cornwall do have specialist nurses but they are on the ward.

 

The panel fed back to the trainers that the process for moving trainees to another department within the Trust needs to be more transparent and those present were in agreement.

 

Cardiology Consultants are often pulled in different directions, for e.g. EM, cath lab etc and it was agreed that additional middle grade cover would help.  It was also agreed that one or two PAs would help ease workload.

 

The panel asked the trainers to consider increased opportunistic teaching.  This might only be an extra sentence of explanation to a trainee.  The trainers described the Friday afternoon teaching provided.  This usually consists of a CbD and is supported by the specialist nurses and led by Dr Devadathan, who is the education lead for the department.

 

It was agreed that there had been a recent focus on improving the quality of SpR training within Cardiology and it is possible that an unintended consequence of this is that the F2 training has suffered.

 

CARDIOLOGY MANAGEMENT

There is a perception that trainees are pulled to areas within the hospital that ‘shout the loudest’, rather than decisions being based on clinical need.  The management team were unclear about the rationale for moving trainees and the panel agreed that this needs to be transparent.

 

The panel discussed:

  • The need for there to be 5 trainee doctors on the ward
  • Whether a role other than a doctor could complete the CIU TTOs
  • Finding a way for trainees to have more experience of the cath lab and in clinic
  • The possibility of recruiting a clinical fellow, which the department agreed to look in to

 

 

Date of report: 10th July 2019

Author: Jane Bunce/Dr Martin Davis

Job Title: Quality Lead / Head of Quality