Neurosurgery Level 2 visit report

Chair Mr Tom Cadoux-Hudson 
Level 2 Visit Date Thursday 8th December 2016 (PEN) and Friday 9th December (SEV)
Trust under review Health Education England, working across the South West

School/Programme/department      under

review
Neurosurgery
Grade of trainees under review All doctors in training
Reason(s) for review

Concerns arising from the GMC NTS

Visiting team (Peninsula)

Dr Jane Thurlow (Director of Medical Education, Taunton and Somerset Foundation NHS Trust)

Mr Steve Eastaugh-Waring (Head of Surgical School and Associate Dean, Severn Deanery)

Mr Bill Wylie (Lay Representative)

Mr Martin Davis (Associate Dean for Quality, Peninsula)

Ms Jane Bunce (Quality Manager, Peninsula)

Mrs Sophie Rose (Quality and Information Coordinator - Peninsula)

Visiting Team (Severn)

Mr Steve Eastaugh-Waring (Head of Surgical School and Associate Dean, Severn Deanery)

Dr Jon Francis (Associate Dean for Quality, Severn)

Prof Selena Gray (Deputy Postgraduate Dean, Severn)

Dr Clare Van Hamel (Head of Foundation School, Severn)

Mr Andy Gadsby (Quality Manager, Severn)

Ms Lynette Cox (Quality Support Manager, Severn)

Ms Lisa Wyatt Jones (Lay Representative)

Mr Geoff Pears (Lay Representative)

Trust team

 

Quality Register Item no. (s)  

 

1. Executive Summary

The South West Neurosurgery training programme is provided across three Local Education Providers: Derriford Hospital in Plymouth, Southmead Hospital and the Bristol Children’s Hospital both in Bristol. The training programme is a run-though programme from ST1 to ST8 with 18 months experience in non-neurosurgery posts within the first two years of the programme.  In the 2016 GMC annual survey of trainees the Neurosurgery programme presented with poor results with red outlier results for ‘overall satisfaction’, ‘adequate experience’, ‘supportive environment’, ‘Access to educational resources’ and ‘study leave’; with pink outlying results for ‘induction’, ‘feedback’ and ‘reporting systems’. Poor results had also been evident in the 2014 survey with a subsequent improvement in the 2015 return. This evidence was triangulated with soft intelligence regarding trainees gaining adequate experience raised through the ARCP feedback process and direct communication with the Postgraduate Dean.

 

As a result of the quality data, the Quality Team of Health Education England working across the South West decided to carry out a supportive review of Neurosurgical training in association with the Chair of the Royal College of Surgeons Specialist Advisory committee, Mr Tom Cadoux-Hudson. The GMC as regulators of the standards of training felt that this was a proportionate response to the intelligence contained within the GMC survey.

 

A visit took place over two days (8th and 9th December 2016), visiting both the Plymouth and the Bristol sites (covering both Southmead and Bristol Children’s Hospital in Bristol). The Bristol review also included a review of foundation trainees’ experience of working within the Neurosurgery unit. A review was not required for non-neurosurgical trainees on the Plymouth site as prior intelligence had not raised any concerns. The outcomes of the Bristol foundation trainees visit will be reported separately. The remainder of this report is dedicated to Neurosurgery programme Speciality Training.

 

The review focussed on three broad themes. These were:

-       Adequate experience of training opportunities

-       Supportive environment

-       Allocation of placements and supervision

 

The conclusions of the report are considered under findings and key themes for the Plymouth and Bristol sites as well as the overall Neurosurgery programme

 

Key Themes Plymouth

At the start of the review, it was acknowledged that in the first 2-3 years of training, Neurosurgery trainees must complete 18 months in other specialties such as Otolaryngology, Emergency Medicine (EM) and Neurology and that this can impact on feedback in respect of their direct experience of neurosurgery.  There can also be a conflict between feedback received through the NTS and the School of Surgery survey due to the way in which questions are focussed, phrased and subsequent benchmarking that takes place. In addition, the relatively small number of trainees can lead to a distortion of survey results, both positively and negatively.  ST3 + tends to receive better feedback as responses become more neurosurgically related, issues can re-emerge in ST6 – 8 as trainees tackle exit exams and are required to hone their specialist  skills.

 

The number of trainees on the on-call rota in Plymouth makes rota management and subsequent compliance difficult. When gaps occur due to under recruitment, out of programme experience, sickness or maternity leave the impact to training is significant. There is a loss of day time working limiting the elective case experience required.

 

Better dialogue between trainers and trainees about swapping specific theatre experience would enhance the exposure to a wider variety of cases to gain training experience necessary to a specific trainee’s level of experience.

 

Designation of specific time in day time theatre sessions to emergency work would enable easier access to these cases hopefully without impacting on the elective case list unduly

 

Key Themes Bristol

At North Bristol Trust the speciality neurosurgical trainees generally had a good experience and appropriate exposure to elective and emergency cases which met the curricular requirements with adequate experience gained by CCT. The experience could be enhanced with a thorough induction and the reintroduction of dedicated teaching sessions. Supervisors should be suitably reimbursed for their educational roles and should aim to complete assessments in a more timely manner. The competing educational demands of NTN holding trainees and clinical fellow posts should be managed and clarified.

 

The Children’s Hospital experience provided a good exposure to Paediatric neurosurgery. Some of the trainees’ experience of administrative tasks could be onerous and the elective work could sometimes be compromised by emergency cases, gaining access to the operating theatre at the Bristol Children’s hospital could also be difficult at times. There could be competing education demands between NTN holding trainees and clinical fellows.

 

Key Themes for the Overall Neurosurgery Programme

The two site training programme with bases in Bristol and Plymouth could appear disjointed with few opportunities for South West trainees to meet for teaching and pastoral support. Attendance at a supra-regional teaching programme was positive. Depending on the site of starting the training programme, trainees expressed a perception that it could feel like two different training programmes taking place in the same region. Trainees expressed concern about communication regarding future rotation arrangements and there appeared to be a lack of clarity about the senior programme educator roles.

 

The programme could be improved by encouraging greater integration of training between the two sites and ensure each sites curricular delivery matches the education needs of trainees.

 

Most trainees find the departments supportive to work in. The visiting panel, as a consequence of listening to the trainers and trainees, had no concerns about the environment in respect of supporting trainees. There was willingness by all to engage in actions that would lead to an improvement in the training programme within the South West.

 

In summary the review demonstrated the Neurosurgery training programme delivers on its curricular requirements and the independent review of log book experience and ARCP outcomes suggest the programme supports trainees to a successful CCT outcome. The requirements and recommendations for improving the experience of trainees on the programme are outlined in full in the following report. 

 

2. Educational Requirements and Recommendations

 

Plymouth Requirements

R5.9a/R 1.12c – Trainees to be allowed to move across lists as appropriate. This will allow trainees to be exposed to learning opportunities appropriate to their curricular needs.

 

Plymouth Recommendations:

R1.17/R1.12 e – Provider to consider additional fellowship posts. The rota is unsustainable with the number of trainees currently employed. An increase in the number of doctors able to participate in the rota will avoid contractual breaches and enable more day time working to facilitate access to elective surgical procedures.

 

R1.15/ R5.11 – All trainees and trainers should be encouraged to discuss the learning objectives and subsequent method of feedback prior to undertaking the surgical procedure so that the learning opportunity can be maximised. This does not need to be the whole case nor be used in all interventions.

 

R1.13 – More structure to each trainees timetabled activity with clarity of responsibilities, particularly regarding ward work, out-patients and theatres. To investigate the practicalities of allocating day time slots to emergency cases to enable these being undertaken more efficiently and being undertaken by trainees with less constraint on time pressures of working outside of ‘normal hours’

 

North Bristol requirements:

R1.13 - North Bristol must ensure that trainees receive a full induction to the Trust and the department when they start.

 

R1.16 –North Bristol must ensure that trainees receive regular appropriate local teaching which occurs during their scheduled working hours.

 

R4.2 - North Bristol must ensure that educational supervisors have adequate time in their job plans to support their trainees.

 

R5.9 - North Bristol must ensure that the scheduled ward rounds are completed each day by the allocated trainee or clinical fellow.

 

North Bristol recommendations:

R1.7 - North Bristol should ensure that there is a fair distribution of roles during operating to ensure educational value is maximised for trainees.

 

R5.9 - North Bristol should review trainee access to spine cases to ensure that trainees are able to complete their require operating numbers.

 

R5.11 - North Bristol should ensure that Work Based Placement Assessments on ISCP are signed off by the Consultant within seven days.

 

 

University Hospitals Bristol requirements:

R1.16 - University Hospitals Bristol must ensure that trainees receive appropriate regular local teaching

 

University Hospitals Bristol recommendations:

R1.7 – University Hospitals Bristol should ensure that there is a fair distribution of roles during operating to ensure educational value is maximised for trainees.

R1.17 - University Hospitals Bristol should review the process when an emergency theatre case occurs whilst an outpatient’s clinic is underway.

 

Programme wide requirements:

R3.7 - The Programme must ensure that trainees are given 3 months’ notice of future rotations especially if it involves moving between Bristol and Plymouth.

 

Programme wide recommendations:

R1.16 - The Lead and Deputy Training Programme Directors (TPD) should engage with the local department education leads to ensure regular teaching takes place in each centre. There should be South West programme wide teaching which would help to achieve the aim of a single training programme rather than two unconnected centres. Innovative teaching technology may assist in this goal.

 

R4.1 - The Lead TPD and their Deputy, who are also the educational leads, should work closely together. There should be clarification about the roles and responsibilities of each individual and their post. The TPD and their Deputy should ensure that trainees are given sufficient notice of rotation dates so that they can plan their training needs and have sufficient time to organise a geographical move.

 

R5.9 - The TPD should continue to closely monitor the operating numbers for each trainee and ensure that each trainee is given adequate opportunity through their placements to meet the minimum levels expected by CCT.

 

R5.9 - The TPD should ensure that the rotations are reviewed in light of the experience all trainees require.  The TPD needs to assure the trainees and the GMC that there is equity of training opportunities independent of the entry site to the rotation.

 

A follow up visit will be scheduled for the Severn based programme for November 2017 to assess progress on these actions. The Plymouth based issues will be monitored through routine quality processes. 

 

3. Good Practice

Neurosurgery

Trainees confirmed that there is a positive relationship between the trainees and trainers within the programme.

GMC Standards R3.3

Neurosurgery

The pass rate for exams is excellent and benchmarks favourably with other UK training centres

GMC Standards R5.1

Neurosurgery

The trainees log books providing evidence of surgical exposure benchmarks favourably with other UK training centres

GMC Standards R5.6

Neurosurgery

The Programme provided across two geographically separate centres endeavours to have only one site change through the eight years of training.

GMC Standards 5.9

 

 

4. Summary of discussions with groups

Neurosurgery Trainees

 

Plymouth:

1. Seven trainees were present for the discussion ranging in grade from ST1 through to ST8. A further trainee provided written comment being unavailable to attend on the day.

 

2. At the start of the review, it was acknowledged that in the first 2-3 years of training, Neurosurgery trainees must complete 18 months in other specialties such as ENT, EM and Neurology. This can impact on feedback.  There can also be a conflict between feedback received through the NTS and the School of Surgery survey due to the way in which questions are focussed, phrased and benchmarked. ST3 + tends to receive better feedback as the focus is on their neurosurgical exposure feedback can alter in ST6 – 8 as trainees tackle exit exams and are required to hone their specific surgical skills.

 

3. The review in Plymouth concentrated on trainees training to be Neurosurgeons and did not cover the Foundation Programme.

 

4. The main focus of the review in Plymouth was:

Adequate experience of training opportunities

Supportive environment

Allocation of placements and supervision

 

5. There isn’t a daily emergency theatre list. Cases are added onto an elective list dependent upon clinical need. This requires either cancellation of an elective surgical procedure or the emergency case being undertaken at the end of the elective list. The latter can mean that the case is then either undertaken by the trainee out of their working hours or by the trainee on-call. Either way it can put pressure on the trainee in respect of time with the rest of the team wishing to leave on time or not too late and knowing that an experienced surgeon would be able to complete the operation much quicker.

 

6. Trainees told the panel that no day case surgery takes place at Derriford. The trainers indicated that day cases do take place but the numbers are smaller than in other areas of the country due to geographical limitations and patient transport to hospital.

 

7. The trainees felt that the organisation (flow of patients) of the theatre list could improve the training experience.  Patients arrive on the pre-op ward prior to going to theatre however operation time can be delayed if no post op bed is available for the patient.  This means that lists fall behind schedule with the consequence that consultants perform the case to attempt keeping the list to the allocated time.  This has a negative effect on the trainee experience.

 

8. Trainees felt that consultants were available for supervision when necessary.  Some trainers take an active approach to the training opportunities where others are reactive or passive in dealing with training opportunities. Some theatre lists did not allow sufficient time for consultants to teach, others were more user friendly for training opportunities.

 

9. During the 18 months training spent achieving the curricula exposure that is not specific to the department of Neurosurgery, one trainee commented that he had experienced concerns about loss of skills in neurosurgery and had consequently organised additional training time within Neurosurgery himself.  He was welcomed by the department in these instances.

 

10. When asked if trainees could swap roles with colleagues to ensure exposure to specific cases required by their level of training as guided by the curriculum, they commented that they had previously tried to implement case allocation according to the needs of individual trainees however this hadn’t worked well due to understaffing of the rota and therefore vital patient tasks potentially not being undertaken.   Trainees feel that the training environment potentially provides sufficient opportunities to meet the curricula requirements but not all had access to the individual needs they require.

 

11. The trainees are currently working a 1 in 8 rota; this had been 1 in 7 and at one point 1 in 6.  The compensatory rest offered had made the rota compliant but had the consequence of limiting the exposure to elective work due to absence from the workplace during the hours this work takes place.

 

12. Trainees told the panel that they are asked for their post preferences half way through each training placement and then posts are allocated according training requirements which usually means the senior trainees are likely to be placed in the posts they have requested.  Allocations are made 3 months ahead of each six month placement. Time is allocated at ARCP to discuss training needs and subsequent post placement.

 

13. Trainees valued regional teaching days which take place every 3-4 months. These are ‘supra-regional involving trainees from other training programmes (Oxford and Wales). They are usually held in Bristol as a central location for the four centres.  Funding a suitable venue and refreshments is dependent upon sponsorship from an outside company. This can be challenging for the trainees to organise.

 

14. Local teaching takes place on a Thursday morning between 10-11am, over recent months this has been very good.  It is trainee led with usually a consultant presence.  A departmental training day takes place quarterly when trainees’ duties are reduced.  This is trainee led with consultant presence and an interactive agenda.  Case based teaching in this setting is valued.  Early morning meetings are valued by the trainees with one of the trainees putting in a lot of effort to be in attendance. The radiology content of this meeting was reported as being very helpful.

 

15. There is no regular, formal communication between the two training centres of the programme.  There isn’t a forum for regular teaching involving the two centres.

 

16. Trainees were asked what single change they would like to see:

  • Timing of theatre lists
  • Theatre and complex cranial exposure
  • Less pressure from everyone in theatre to ‘crack on’ – this unwittingly puts pressure on the trainees when trying to develop their competencies

 

Bristol:

North Bristol Trust: 7 Higher trainees were present

 

17. The Trainees explained the usual working pattern of on-call (1 in 14 split nights) which is covered by middle grades (ST3+).

 

18. During the working day there are three neurosurgery theatres.  Out of hours there is the 2nd emergency theatre which acts as essentially aNeurosurgery theatre with a 24hr Neurosurgery scrub team available.

 

19. Trainees stated that it is very rare for an elective case to be moved for an emergency.

 

20. The trainees noted that they get good exposure to cases in North Bristol and overall feel that they will achieve their required numbers though trainees were very concerned about it. The SAC confirmed that reviewing data for recent CCT holders in the South West that it has a very good record of trainees achieving above median case numbers by CCT.

 

21. The trainees felt that if they were in Bristol from ST1 – 8 they would struggle with achieving their numbers as a lot of the simple index cases such as lumber spines are outsourced to the independent sector where they do not operate.

 

22. Trainees felt that if they started in Plymouth then moved up to Bristol half way through their training, they would be best placed to achieve their case numbers. If it was the other way around, then they felt they would struggle, as Plymouth is very good to get the increase the core operating cases, whereas Bristol is very good on the more complex surgery. Trainees feel that they are disadvantaged if they do not start their training in Plymouth.

 

23. Programme wide regional teaching occurs every three months and is linked with Cardiff and Oxford. Trainees stated that they felt this was a good programme.

 

24. Once a month there is local teaching at North Bristol which is consultant led. In April this was re-established which the trainees welcomed. It was thought that is was not possible to technically link the teaching with Derriford through the use of IT.

 

25. Trainees felt that there doesn’t seem to be much planning with regards to rotations and a number of trainees have been told of their new rotation within six weeks of it starting which feels very last minute.

 

26. There has not been any departmental induction in the past, though trainees noted that this is trying to be fixed for new starters. The trainees commented that the recent induction programme was satisfactory.

 

27. Overall the trainees felt that clinical supervision was good and they all felt that if they needed help they could get it.

 

28. Educational supervision could be variable depending on the individual who can be very busy. All consultants are happy to teach.

 

29. Trainees try to complete their ISCP each day though there is limited consultant engagement with the V10 changes and it can take a while to get the consultant to sign off the operation notes. TC-H noted that some centres recommended that work based assessments should be completed with 48hours of the practical assessment taking place.

 

30. Trainees reported that the ward system had recently changed. The details are covered in the Foundation report. Overall the trainees like the new system as it enables more teaching and it enables them to get to theatres on time. It was also noted that it was a better system for less than full time trainees.

 

31. It was noted by some trainees that some individuals did not cover their rostered ward rounds. There was a feeling that it was usually the clinical fellows who did not complete the ward round or engage fully in supporting the junior ward doctors. It was felt that this seemed to show a general difference between the clinical fellows and the trainees where the trainees felt that they have picked up gaps left by the fellows.

 

32. It was expressed by some trainees that the educational needs of NTN holding Trainees could compete with those of the Clinical Fellows. On occasions both could be allocated to the same theatre case and the educational outcome of the NTN trainees were not always clear where completion was evident.

 

33. Trainees felt that there were some consultants with a workload which was mainly service based and therefore less suitable for trainees. Previously trainees were not allocated to these consultants, however more recently this has changed. 

 

University Hospitals Bristol (UHB):7 Higher trainees were present (same session as above)

34. It was noted that there is one post that usually last 9 – 12 months in University Hospitals Bristol, which is based in the Children’s Hospital. Trainees rotate through this post as part of their time in Bristol.

 

35. There are three theatre lists per week for elective work. The emergency work is fitted in around other cases.

 

36. Some trainees expressed concern about ensuring that they complete enough operations as the time in UHB can be light on operating cases.

 

37. Trainees felt that a large part of their on-call time was spent trying to arrange the scans for patients as they often co-ordinated it all. It was noted that the nurse practitioners were very good but they could not request scans or support getting them processed which meant that more work fell on the trainee.

 

38. Trainees recognised that the operating experience is very good once you get into theatre. The problem is that lists can be cancelled due to bed pressures, issues with theatre time or theatre staffing.

 

39. There were two outpatient clinics per week but they can coincide with holding the bleep and emergency theatre cases leading to the clinic being cancelled at the last minute. Also at times the consultant may not be present. However, trainees felt that they could get support if they were running a clinic without a consultant present. 

 

40. There has been no local departmental teaching for the last four months. But there is now a new plan to move the teaching slot to a Tuesday morning which the trainees welcomed. Through it was noted that currently there are no facilities to link this with Derriford or the Bristol sites.

 

Neurosurgery Trainers 

Plymouth:

41. Six trainers attended the meeting.

 

42. The trainers explained that Monday to Friday there are three Neurosurgery theatres.  A spinal list takes place on Saturday. Emergency cases usually take place on a Saturday morning although this is not a fixed session.  During the week there isn’t an allocated emergency list for Neurosurgery.  The trainers explained that the provision of an emergency theatre had previously been discussed with the trust, but the decision made that this would not always be utilised efficiently. Emergency cases that arise during the day are undertaken on an elective list with the consequence of another patient being displaced or the list over-running.

 

43. The trainers confirmed that elective lists can start late due to various delays and that trainees’ opportunities can be lost as pressure mounts to fulfil the service requirements.  They felt that delays to theatre start times as late as 10.30am were usual.  The first patient is usually sent for at 8.30am, patients are taken to theatre at around 9.15am to receive their anaesthetic with surgery starting between 9.30am and 9.45am.  It was acknowledged that there is a major issue with ITU beds and some operations are delayed or cancelled because of lack of ITU bed availability

 

44. One option presented by the department was to move the routine operating day to start at 11.00am and finish at 7.00pm. This would improve the training opportunities by ensuring that the operating list starts on time. This had previously been discussed between the department and the trust but not agreed/taken forward.

 

45. Trainers confirmed that day cases do take place where appropriate.  However, many patients coming to Derriford have to travel long distances, have co-morbidities, high BMIs and it may not be appropriate for the individual to be a day case. 

 

46. The trainers confirmed the post allocation described by the trainees.  The trainers explained that the more junior trainees are not given the first choice of posts as their training needs are more generic and therefore a wider range of posts would be able to fulfil these compared to a more senior trainee.  They explained that they try to ensure trainees are only required to relocate once during their neurosurgical training which minimises personal disruption.  The panel was informed that trainees learning requirements are discussed at the fortnightly consultant meeting.

 

47. Most trainers confirmed that they had no objections to trainees changing duties between themselves in order to ensure they get access to procedures necessary for their level of training and the alteration therefore benefits their training needs.  It was also acknowledged that there is opportunity for senior trainees to train their junior colleagues in some procedures. This could be encouraged more by the department.  Trainees could also double up on cases and both individuals still benefit from the training opportunity.

 

48. The panel was informed that in a seven week rota cycle, trainees will be unavailable for two weeks during the day time in addition to any planned study or annual leave taken during that time period.  This reduces the exposure to elective cases. It also takes time for the trainee and trainer to develop confidence in their current level of abilities which again has an impact on exposure to suitable cases for training.  Trainers also felt that trainees don’t fully appreciate that to enter a procedure in their log book they don’t necessarily have to have undertaken the whole procedure.

 

49. It was agreed that an increase in trainee numbers would facilitate a more robust rota allowing compliance during time of leave or inability to recruit. It would also have the consequence of increased trainee availability during normal working time.  A 1 in 10 rota would produce a sustainable working pattern for the future.  To achieve this would require the appointment of non-training grade doctors to the department.

 

50. The panel fed back the positive comments made by trainees on radiology teaching at the morning meetings.  The trainers confirmed that the radiologists are committed to continuing this practice.

 

51. The trainers felt that feedback on their performance as trainers would be welcomed and HEE SW agreed to facilitate this process.

 

52. A team building experience for the department was also felt to be something that would enhance the departments working relationships with one another.

 

53. The trainers felt that a 6-monthly trainee survey would also help them improve the training experience by providing additional feedback to the GMC NTS. 

 

54. ACTION: HEE SW agreed to provide detail behind the GMC questions for 2016 and provide some data comparing the best and worst performing programmes nationally.

 

55. The department expressed a commitment to once again being considered the best training programme in the country.

 

Bristol:

56. The review did not have a session directly with trainers, though they were involved with the Trust host teams and they expressed their views as part of those sessions. 

 

4. Programme-wide findings

The South West Neurosurgery programme is an 8 year run-through training programme from ST1 to ST8, based around 2 geographical locations in the South West of England, Plymouth and Bristol. Neurosurgery training in Plymouth is delivered at Derriford Hospital site (Plymouth Hospitals NHS Trust). In Bristol the majority of higher speciality training takes place at Southmead Hospital (North Bristol Trust), Paediatric Neurosurgery training takes place as the Children’s Hospital on the University Of Bristol Hospitals Foundation Trust site which also hosts the early year’s non-neurosurgery placements of the training programme such as ENT and EM.  

Prior to the visit some concerns had been raised by trainees about adequate experience being gained at key points within the programme. The Chair of the Neurosurgery Specialist Advisory Committee, had conducted an independent review of ARCP outcomes as well as a review of log book experience comparing the data with other UK training programmes. He was able to feedback to the visiting team that the South West Neurosurgery programme provides good education outcomes with comparable CCT achievements, ARCP outcomes and log book experience when compared to other UK training programmes.

It was acknowledged that trainees in the first two years of the programme spend up to 18 months in non-neurosurgical but essential specialities such at Neurology, Otolaryngology and EM. This is essential to help achieve neurosurgical competence as trainees’ progress. Some posts such as otolaryngology at UHB were thought to be excellent whereas trainees considered the experience in Emergency Medicine was less valuable for Neurosurgical training. The curriculum however requires a minimum of 4 months EM, 4 months Neurology and 6 months in another surgical speciality.

It was also discussed at both sites that trainees in the early to middle part of the programme can express concerns about numbers of cases being performed but by the end of the programme the trainees case load is adequate to achieve CCT and is good when compared to other programmes in the UK.

The perception from the trainees was one of two differing training experiences depending on whether one started in Plymouth in the early years rotating to Bristol for the latter years or vice versa. The general view from trainees was that the preferred option was to start in Plymouth where good early exposure to more simple cases, including spinal surgery, could be gained and on rotating to Bristol with some experience the trainees were able to access more complicated intracranial cases. The trainees who started at Bristol expressed concerns about not having exposure to more complicated intra cranial cases when rotating to Plymouth.

Action: The TPD should ensure that the rotations are reviewed in light of the experience all trainees require.  The TPD needs to assure the trainees and the GMC that there is equity of training opportunities independent of the entry site to the rotation.

 

The trainees reported that there were little opportunities for the South West trainees to meet as a cohort. Regional Teaching did happen every 3 months along with the Oxford and Wales Training programme. The trainees valued this teaching and reported it to be of good quality. The Plymouth site provided teaching regularly which was well valued by the trainees.  Teaching had restarted in North Bristol Trust in the month prior to the review which was welcomed by trainees. There was no teaching taking place at the Bristol Children’s Hospital.

Action: The Lead and Deputy TPD should engage with the local department education leads to ensure regular teaching takes place in each centre. There should be South West programme wide teaching which would help to achieve the aim of a single training programme rather than two unconnected centres. Innovative teaching technology may assist in this goal.

The Educational Governance of the Neurosurgery training programme is overseen by a lead TPD which alternates between the Plymouth or Bristol site with an appointed Deputy to succeed at the other site. At the time of the review the lead TPD was a consultant in Plymouth and the deputy TPD was a Bristol consultant at the Children’s Hospital. Some trainees reported not knowing about rotation movements until very close to rotation dates. They would appreciate more notice of rotation changes. During the discussion the trainees did not feel that the programme felt like one overarching programme and that the Plymouth and Bristol sites felt quite separate. The trainees also discussed a number of examples where there was lack of clarity as to who should be approached for particular issues. There was some confusion at the Bristol site about the role of the clinical departmental lead for Neurosurgery and the deputy TPD who is also a Bristol based consultant. Both the lead and deputy TPD valued each other and respected the help they could offer one another when dealing with difficult issues. The chair of the Neurosurgery SAC indicated that some UK training programmes have separate TPDs for ST 1-3 and ST4-8 to cover the different educational demands of junior and senior trainees.

Action: The TPD and their Deputy should work closely together. There should be clarification about the roles and responsibilities of each individual and their post. The TPD and deputy should work closely with the educational leads in each department and clear role distinctions between the education lead and TPD should be obvious to the trainees.  The TPD and their Deputy should ensure that trainees are given sufficient notice of rotation dates so that they can plan their training needs and have sufficient time to organise a geographical move.

 

The perception of the visiting team and the comment from the majority of trainees was that the training programme was valued and enjoyed.  The South West programme achieves the outcomes required by the GMC and Neurosurgery SAC. The split site programme presents challenges and opportunities in ensuring that all trainees gain the maximum educational experience. The TPD role is key is trying to bring the programme together and the above actions could enhance the training experience of Neurosurgeons in training. 

 

4. Quality Process

Once the panel Chair has shared and agreed this report with all attendees for factual accuracy, it should be sent to the relevant Quality Manager (see below).

The final report will be issued to the DME by the Quality Team, as appropriate.

 

Quality Managers:

Peninsula: Jane Bunce (jane.bunce@southwest.hee.nhs.uk)

 

The Quality Team will review and update the quality register and report to the General Medical Council (GMC), as appropriate.

 

5. DECLARATION BY CHAIR

I confirm this completed report is a true and accurate account of the level 2 visit. The key recommendations have been identified within this report in good faith.

I confirm that any significant areas of concern e.g. trainee safety or patient safety concerns have been brought to the attention of the relevant Director of Medical Education (or equivalent) and Medical Director for immediate attention.

 

Name:  Dr Martin Davis (Associate Dean for Quality)                               Date: 27th February 2017