Obstetrics and Gynaecology Level 2 visit report

Chair Miss Susan Bates/Prof Val Heath
Level 2 Visit Date Tuesday 21st February 2017
Trust under review Northern Devon Healthcare NHS Trust

School/Programme/department under review

Neurosurgery
Grade of trainees under review ST1
Reason(s) for review

Concerns arising from the GMC NTS

Visiting team

Miss Susan Bates (Head of School)

Mr Ben Peyton-Jones (Training Programme Director) 

Professor Val Heath (Practice Placement Quality Lead)

Mr Robert Moor (Lay Representative)

Mr Neil Squires (Specialty Training Manager)

Miss Amy Borland (Trainee Representative)

Mrs Sophie Rose (Quality and Information Coordinator) 

Trust team

Darryn Allcorn

Toby Cooper

Dr George Thomson, Medical Director

Dr Guy Rousseau, Interim Director of Medical Education

Mr Osama Eskander, Clinical Director

Mrs Eleni Lekoudis – Royal College of O&G Tutor 

Quality Register Item no. (s)  

 

1. Executive Summary

The response to concerns visit was conducted to evaluate concerns about the quality of training opportunities available to the specialty trainees in Obstetrics and Gynaecology in North Devon Hospital Trust. There had also been indications that the working within the multi-professional team was leading to environment of potential undermining and ineffective working. These concerns had arisen from outcomes of quality panels relating to postgraduate medical education. Triangulation with existing data pertaining to non-medical learners did not identify concerns.

The visiting team spoke to key individuals in the department and organisation.
A number of requirements and recommendations have been made. These are listed in the relevant section.

The visiting team felt that the current educational capacity of the Trust was sufficient to provide training opportunities for a single ST1 in the specialty. The second educationally approved post will not at present be recruited to.
An interim review of progress in meeting the educational requirements given will take place in 3 months with a formal report and update being made in 6 months.

 

2. Educational Requirements and Recommendations

Educational Requirements

The junior doctor rota is reviewed to allow increased training opportunities in out-patients, delivery suite and theatre.

Suggestions for achieving this are:

1. Reducing frequency of on call by joining a ‘Hospital at Night’ rota.  Local example: Torbay Hospital. This may help other specialties and reduce overall frequency of night duty leading to greater daytime training opportunities.

2. Removing junior doctor from night duty by running shifts to 11pm only.  

3. The RCOG tutor has sufficient time allocated within their job plan to undertake key activities of the role e.g supervision and teaching of trainees within the speciality, attend School Board, ARCP’s .

4. Basic ultrasound training to be available to ST1 O&G.

 

Educational Recommendations

At the time of the visit changes were noted as being made already to improve the training environment specifically through collegiate working and enhanced multi-disciplinary communication.  These should continue so the already moderated divide between medical and non-medical staff should be erased.

In addition:

The panel also recommend that:

1. Provide more daytime emergency assessment capacity for early pregnancy and gynaecology emergencies.

2. Provide senior access to GP’s for advice such as ‘hotline’ by day and to middle grade doctors at night, with aim of reducing night time admissions.

3. Delivery suite lead has regular weekly protected time for governance, training and supervision on Delivery suite.

 

3. Good Practice

Obs and Gynae Team, Maternity and Gynaecology team

Team Development by Human Factors Training.

Domain 1, 2 and 3



4. Summary of discussions with groups

The Trust Executive Team recognise the cultural issues and risk adverse atmosphere within the department and have used an external facilitator with experience of working with dysfunctional teams and been awarded a grant from Health Education England to undertake Human Factors Training.  It was also noted that there had been investment in the simulation suite with a new mannequin expected imminently.  

 

There had been concerns locally regarding the Sustainability Transformation Plans (STP) due to rumours and reports in the press that the unit may close.  It was noted that whilst there are a small number of deliveries in North Devon compared to other units there are no plans to close the unit and the geography of the region would suggest this would be unlikely.

 

It was noted that the number of vacant posts had been detrimental to the trainee experience.  Presently only one of the two ST1 Obstetrics & Gynaecology posts is filled and there are several vacancies on the General Practice programme which would rotate through the specialty.  It was noted that recruitment into General Practice is difficult in most regions and in recognition of the significant challenges faced by North Devon five posts have been allocated funding as part of the Targets Enhanced Recruitment Scheme which provides an incentive in the form of a £20,000 salary supplement.  In addition there will be posts that rotate with Exeter from 2017 in an effort to improve fill rates. 

 

ST1 Trainee

Two ST1 posts are allocated to North Devon but presently only one post is filled. 

 

Feedback from the current ST1 trainee offered assurance that there is sufficient training opportunity to attain ST1 level competencies despite the low number of deliveries compared to larger units within the region, for one trainee.  It was noted that the experience gained relied on the assertiveness of the doctor to seek out training opportunities but was also dependant on posts being filled (i.e. GP and Foundation posts within O&G department).

 

The SHO rota is a 1:6; i.e. one week of nights every six weeks.  When account for compensatory rest ‘post nights’ is taken the trainee is not available for daytime work for two weeks out of six.   The frequency of night shifts increased if there are gaps in the rota.  Locums appointed to fill gaps were of a variable standard and could not be relied upon. 

 

It was noted that there were limited training opportunities at night. 

 

No barrier to training from the midwives was identified.   The current ST1 found the department enjoyable, with middle grade doctors and consultants willing to teach.  Concern was raised about being the only Obstetrics & Gynaecology trainee at the Trust which can be isolating for a doctor in their first year of specialty training.  It was also noted that a second ST1 level trainee may dilute the training experiences given the number of opportunities available.   The new RCOG Tutor has been very supportive and no safety concerns had been identified.    

 

The ST1 Obstetrics and Gynaecology trainee is responsible for managing the rota which has allowed mutually agreed swaps to enable leave to be taken. No concerns were raised regarding access to study leave or annual leave. 

 

The ST1 Obstetrics and Gynaecology trainee has been involved in improving the department induction process and has inducted locum doctors.

 

Junior trainees take GP calls and admit patients through A&E. There is a lack of EPAS appointments and no Emergency Gynaecology Unit so it is difficult to avoid night time admissions.

There is fortnightly teaching programmed in but it is difficult to attend given there are so few trainees.  MDT and Risk Management meetings occur monthly.  

 

 

Junior Doctors (Foundation and General Practice)

Two Foundation Year 2 trainees and two General Practice trainees were interviewed as part of the review.  The experience of these doctors was not dissimilar to that of the O&G trainee. 

 

The trainees gave positive feedback about the department which was friendly with experienced Staff Grades and supportive approachable Consultants.  However there were limited opportunities to access clinic, primarily due to staffing shortages. 

 

Positive comments were made about the departmental induction and access to study leave, however, it was noted that there was limited educational value from the night shifts.  It was also noted that teaching rarely happened. 

 

The juniors also commented that too many patients are admitted at night due to SHO’s accepting GP calls and the poor access to daytime emergency assessment.

 

 

Meeting with Supervisors

The Specialty Lead, and the RCOG Tutor  were interviewed. They outlined the positive changes being introduced and their future plans to develop education and training. They accepted there had been cultural issues in the department which had impacted on training over the past few years and consider that much progress has been made in team working, governance and safety recently.

 

More teaching at handover has been introduced and as Labour Ward Lead, The RCOG Tutor has requested more regular sessions on delivery suite to enhance governance and teaching further. They acknowledged that it is difficult to form a medical group for a teaching programme but plan to increase multidisciplinary teaching with CTG and CS review on Delivery suite as well as more simulation/scenario training.

 

The on call rota was acknowledged as an issue especially when the posts were vacant. Access to EPAS and an EGU were discussed and the possibility of joining a ‘hospital at night’ rota with other specialities.  It was suggested that they may wish to consider removing the SHO from the night time rota to increase daytime availability where there are greater training opportunities. 

 

The Specialty Lead asked if it would be possible to allocate a senior (ST6/7) trainee to the department. This would encourage the ‘training environment’ to benefit junior trainees and midwives. The Specialty Lead offered advanced skills training (ATSM’s) for the senior trainee. This request was discussed with the panel which felt that advanced obstetric skills could not be offered or maintained in North Devon. It is unlikely therefore that any trainees other than ST1 would be allocated to North Devon.

 

Overall a very positive discussion was held with a number of suggestions discussed.

 

Midwifery Team

Attendees

Senior Governance Manager

Supervisor of Midwives

Head of Midwifery

Band 6 Midwife

Lead Midwife for Normal Birth and Inpatient Services

Executive Nurse

 

The midwifery team described a multi-professional journey that the Obs and Gynae department had been taking for some years.

 

This included:- 

  • A move from an extremely hierarchical structure (medical/non-medical) to one that is now more collaborative team working.

 

The midwifery team identified how new consultant personnel had contributed positively to better team working. Particular emphasis was given to the work of EL as a change agent. Evidence was offered as to the value of consultants being attached to midwifery teams and the contribution that made to a positive working and learning environment.

 

That said there appears to be further work to do.

 

Examples were given of unhelpful responses given by consultants when midwives raised concerns in the interest of mother and child.  The midwives perception is that it is not encouraged to question some consultant’s decisions. Phrases such as ‘How dare you challenge me’ were reported as used. That said, the midwives were perfectly clear that patient safety has not been put at risk when these conversations had occurred. 

  • No embedded risk processes ,poor governance processes and poor outcomes- now addressed

 

As midwifery concerns regarding risk and governance processes were identified, plans to introduce change, had in the past, not been well received by the wider team. This has now improved significantly and assisted the planning for the multidisciplinary training needs analysis and shared education processes.

 

Concerns raised were escalated to the TDA and LSAMO (Lead Supervising Authority Midwifery Officer), the latter being involved in developments throughout.

 

Progress has seen a significant reduction in Serious Incidents requiring investigation. 

  • A move to a multi- disciplinary team training analysis- in place.

 

A number of examples were offered where a training needs analysis has been resultant in shared educational activity and improved outcomes.  These included:-

  • Human Factors Training (grant applied for by Head of Midwifery to HEE- successful)
  • Gap Grow- fetal growth monitoring
  • Blood Transfusion
  • Consultants attached to midwifery teams leading on specific responsibilities in line with the Better Births initiative.
  • A multi-disciplinary handover is now in action across both wards.

 

That applauded, examples were also offered where work is yet to be done to ensure a full understanding of the approach to be taken in abnormal situations. In addition, the midwives believed there was a lack of understanding from some colleagues as to the midwives scope of professional practice. 

  • A maternity action plan received and risk registered at Trust Board level- now implemented.

 

The executive team of the hospital have been engaged throughout this journey. Medical lead for Obstetrics and Gynaecology and lead for Midwifery have direct access to the Board. Monthly meetings now occur between the Medical Director, Executive Nurse, Patient Safety Manager, Head of Midwifery, Lead Clinician for Women’s and Children’s Health and the Divisional General Manager.

 

In Summary, progress has been made. There has been a huge improvement over the past two years in particular.  However,   concerns still remain about a divide between the medical and non-medical staff and the lack of support for junior medical staff by some of their seniors. 

 

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: 9th May 2017