Postgraduate School of Medicine Quality Management Visit to Royal Devon and Exeter Foundation Trust

March 2015

 

Primary author of report (name and job title): Dr Alison Moody, Training Programme Director

Provider visited: Royal Devon and Exeter Foundation Trust

Date(s) of visit: March 2015

Visit team (names and educational job titles):

Chair

Dr Alison Moody, TPD

Medical externality

Lay Rep

 

Dr Phil Bright

Mr Bill Wylie

 

   

Programme

No. of trainees seen

No. of trainers seen

CMT, Respiratory, Gastro, Diab & Endo, Geriatrics, Rheumatology, Cardiology, Acute

 

 

Evidence considered prior to review taking place: Feedback questionnaires from some of the trainees and trainers

None

Date visit report ratified by HESW – Peninsula

11th November 2015

Date visit report made available to provider

11th November 2015

Date provider ratifies visit report

12th November 2015

Circulation of this report: Peninsula Postgraduate Medical Education Quality Team

Director of Medical Education and Medical Education Manager

 

Executive Summary

 

The visit to Royal Devon and Exeter Hospital was well-organised and well attended. Due to the large number of TPDs working in Exeter other members of training committees attended in their place. This was also true of the Head of School of medicine who is a consultant at Royal Devon and Exeter Hospital.

The overall themes from the day were very positive with happy trainees and trainers both feeling that their trainees are receiving a good quality training experience.

The usual issues of training vs. workload were highlighted with the Core Medical Trainees particularly stretched at times and feeling achieving some of their training goals was difficult.

There were no concerns raised at the LEP visit that required immediate attention by the Trust.

Please note: The LEP report was difficult to write as the author only received summary feedback from Gastroenterology and Care Of the Elderly, other specialities did not send reports with recommendations so the report is written entirely from notes taken on the day.

 

 

Key recommendations

1

Dermatology

Clearly define educational vs. service commitments e.g. complex case meetings which should be educational but are often service. Develop a more formal teaching programme to help cover the curriculum.

6 months from publication of report

2

Gastroenterology

Ensure processes in place that junior doctors are not asked to consent for endoscopic procedures

Ensure adequate access to endoscopy to meet the curriculum requirements with better coordination of service/therapeutic and training lists

6 months from publication of report

3

Trust-wide

Consider a local training session to help Specialist trainees complete SLEs for junior doctors

6 months from publication of report

4

CMT

Ensure that trainees are released from service commitments to achieve their CMT training with a particular focus on OP clinic experience

3 months from publication of report

5

Respiratory

Trainees and trainers should work together to look at the registrar roles within the department

Consider strengthening departmental induction with a departmental handbook and timetable

3 months from publication of report 

6

G(I)M

Ensure that there is a specific GIM induction for CMT and SpRs

6 months from publication of report 

7

ITU

Ensure ITU discharges are timely with adequate handover to the receiving team

3 months from publication of report 
     

 

Departmental Reports

Clinical Genetics

The panel (chair and 1 member) was able to interview one ST5 trainee in the department (the only one in the department). This trainee described excellent generic training opportunities in terms of infrastructure and enthusiastic consultant support. There was no difficulty in fulfilling the curriculum and undertaking WPBA. The unit did not offer ‘specialist’ training but the trainee was able to acquire metabolic training outside the region with no difficulties. In addition, the trainee was allowed significant flexibility in obtaining in house training as she is essentially supernumerary (the service delivery was fully consultant based). The trainee also received satisfactory support in both clinical and education supervision. The trainee also described weekly departmental meetings that she was expected to attend and participate. There were no reported problems in accessing regional teaching and study.

 

Gastroenterology

Rota gaps and high numbers of General Medical admissions meant that the Registrar was incredibly busy. He was heavily involved in the general medical take and supervised between 40-50 inpatients on gastroenterology wards. Combination of the above factors led to lack of adequate numbers of attended gastroenterology clinics and endoscopy sessions.

The endoscopy department in RD and E Hospital has 4 endoscopy rooms which are shared between Gastroenterology, Respiratory and Urology. According to trainees this further contributes as a limiting factor to the availability of the endoscopy training lists. The gastroenterology trainee in 6 months performed 37 gastroscopies and 20 colonoscopies which is below what would be expected at his stage of training.

From February 2015 there are now 2 gastroenterology registrars which should increase SpRs flexibility and improve their ability to attend endoscopy sessions.

Regular teaching sessions occur within the department

There is an induction in place for gastroenterology but not for General Medicine

There is allocation of ES/CE as appropriate. ES roles are recognised by the Trust. SpRs are able to have regular assessments which they value.

Registrars felt well supported despite heavy workload

Key Recommendations

1. Ensure adequate access to endoscopy to meet the curriculum requirements with better coordination of service/therapeutic and training lists

2. Clarify who to ask for annual professional leave

Care of the Elderly

RD&E are providing excellent training to the Geriatric Registrars and should be congratulated.

The RD&E training programme is co-ordinated by Dr Ray Sheridan, who as the TPD for Geriatrics, fully understands the training requirements and ensures a comprehensive educational package tailored to the individual trainee. He is supported by an enthusiastic and seasoned team of educational supervisors – one (Dr J Sword), should be congratulated on the superb work she has undertaken with recent trainees who have required considerable additional support. All the trainees felt they were gaining a broad experience, both in-patient and out-patient. Overwhelmingly the trainees felt they were well supported by their consultants from a clinical perspective but given enough responsibility to feel they were practicing at a Registrar level. Equally educational supervision was praised very highly. Their supervisors had actively encouraged them to do SLEs when interesting/relevant cases presented themselves.

The trainees felt they had good weekly departmental teaching and that they were given the chance to present cases and teach the department. Protected educational sessions were an aspect of all trainees’ timetables but as in common with many trainees – this is not always taken due to the feeling by trainees that the wards are too busy.

Induction was felt by all trainees to be comprehensive. The ST3 also welcomed the Geriatric training programme induction given by Dr Sheridan and the chance to meet up with other new ST3 trainees. RD&E is a sizeable teaching hospital - the only subcomponent of the stroke curriculum not met is neurosurgery/neuro ITU which is easily accessible at Derriford hospital.

Trainees felt the white card referral system, although of good educational value was disorganised. The trainees felt that if the referrals were phoned through or bleeped to a Geriatric SpR of the day, rapport with the referring team junior could establish tasks that could be done in advance of their review and then the review and their time, could be a more efficient process. This may be something a trainee may like to take forward as a QI project?

The only other criticism was that a lack of a stroke registrar, due to a vacancy in this post, had led the Stroke Specialist trainee to feel this impacted on her education time. This issue was explored with the stroke consultant trainers and it appears the trainee may have underestimated the time that a stroke consultant was around to provide senior support to allow the trainee their allocated educational time.

From a trainer perspective the feedback was also all very positive. There appeared to be a strong training ethos amongst department members. Regular supervisor meetings took place with time available in job plans for educational supervision. The trainers felt very well supported by the deanery, particularly with respect to trainees who needed additional support.

The educational opportunities were clearly highlighted to trainees and there was always the opportunity to allow senior registrars the ability to act up as Consultants in their last year of training.

Summary

There appear to be no concerns regarding the Geriatric training at RD&E and that actually the opposite is the case with a happy bunch of trainees and an experienced group of trainers, who should all be congratulated for their efforts to produce future Geriatricians. The Geriatric experience encompasses all areas of the curriculum and the trainees appear well supervised and supported. The educational aspects of the department appear to be expertly managed by Dr Ray Sheridan, but I would like to make an additional mention and thanks to Dr Jane Sword for her time invested in dealing with trainees needing extra support.

Key recommendations

  1. Encourage a trainee to look at the referral system into Care of the Elderly from other specialties.

 

Dermatology

The overall theme for dermatology trainees was that they were happy in Exeter and felt it was providing good training opportunities, but that some were missed due to the massive service demands on both trainees and trainers. This was acknowledged by all people who attended. Trainees found the supervisors very approachable and friendly

Specific issues for the trainees included:

  • Some parts of the curriculum difficult to achieve including photobiology, genetics and some aspects of pathology
  • Some educational opportunities e.g. complex case meetings are missed due to high pressure to see other types of patients e.g. 2 week wait patients
  • Lack of formal educational opportunities
  • Lack of awareness around reflective practice and the importance of an up to date PDP

The trainer who attended acknowledged the high level service demand has an impact on delivering training.  He was very clear that new trainees need extra support and that is acknowledged in outpatients setting

Key recommendations

  1. Ensure adequate teaching delivered to trainees
  2. Explore possibility of study leave budget being allocated in one tranche to allow funding for expensive courses

 

Renal trainees

On the whole trainees and trainers were very happy at Exeter Hospital. Training was appropriate for all levels of trainee and was adjusted according to level of seniority.

Departmental induction was comprehensive and helpful.

ES roles were well fulfilled and there was plenty of opportunity to discuss patients at any time. Some concerns over supervision for the GIM component of the posts were raised. It appears that the renal physicians felt there should be a separate GIM ES. This is not a theme through other specialities and may reflect that on the whole renal medicine is more separate from GIM. Currently the ES receives feedback from acute physicians about on take performance. ES would like a more robust feedback process for ES reports and their general performance.

Departmental teaching occurs regularly and was well received. Trainees have the opportunity to attend regional teaching days in renal and GIM.

Concern was raised over consent for endoscopy (see key recommendations above).

 

Rheumatology

The trainee was happy with their training. They have a supportive team and ES. The curriculum is well covered. Some discussion took place around speciality clinics and all felt this may be a valuable addition to current training. The trainee did not feel they had received adequate training to complete SLEs for junior trainees – no local training in place. Also no training around how to ‘reflect well’.

ES was well supported by Deanery and colleagues.

Key recommendations:

  1. Explore the possibility of attending combined clinics
  2. Trust to explore setting up training for all SpRs in how to complete SLEs

 

Respiratory

Overall a very positive impression of the department. A good range of specialist opportunities, a GIM component that is not seen as too onerous and supportive approachable consultants mean the trainees are happy on the whole.

The trainers have an accurate perception of the trainees concerns which focus on the distribution of work across 3 registrar posts. There are 2 ward based posts and one OPD post. The OPD post is seen by the trainees as hard work and unsustainable for long periods especially when cross-covering ward work. The trainees think that the registrar posts need redesigning, the trainers are not convinced of this. Trainers appear enthusiastic and well engaged with the juniors – they are interested in providing a good training experience and put a lot of effort into achieving this.

Trust induction comprehensive, departmental induction largely verbal but trainees were happy with it. No formal ‘on call’ induction but trainees felt handover at first on call was adequate. ES support good across the department.

Key recommendations:

  1. Trainees and trainers should work together to look at the registrar roles within the department
  2. Consider strengthening departmental induction with a departmental handbook and timetable

 

Neurology

Trainees and trainers were very happy with the posts in Exeter. Trainees felt they were given every opportunity to attend clinics to compliment the curriculum and were grateful for the flexibility. Trainers obviously take training seriously with ‘training’ clinics where time is set aside for discussion.

Induction is very thorough and clinical and educational supervision excellent. Trainers were frustrated by portfolio changes (a common theme) and would value regular Deanery updates of changes.

Only concern was of a lack of CMT ward cover due to empty post and then LTFT trainee in a fulltime slot. All felt this could lead to a patient safety issue and be detrimental to the SpR training if it were to occur again.

 

Haematology

Haematology trainees found the post useful and enjoyable. They had a good depth of experience. Supervisors were friendly and approachable. The trainee interviewed could not recall a departmental induction having taken place. Trainee felt regular formal teaching was less good and needed strengthening. Trainer felt there had been some effort to deliver formal teaching but time constraints on both sides made this difficult.

No concerns identified.

 

Cardiology

Trainees were happy with the broad range of experience they have received at Exeter. They had a good induction and had no concerns about supervision in their day to day activities. There were no formal teaching sessions but trainees seem to feel that they learned a lot day to day and there were regular clinical meetings to discuss cases.

No concerns identified

 

Core medical training

CMT felt that all the posts they did provided valuable training. However, they were often busy and getting to clinics was a challenge for all. This sometimes necessitated taking annual leave to achieve this.

They received good departmental induction but no GIM induction to the take etc.

Respiratory was particularly noted to be an extremely busy post. COE and Gastroenterology were both noted as providing very good teaching.

Trainees were sometimes asked to consent for endoscopy procedures and seemed unaware of the requirements for training when asked by the external assessor.

One trainee was concerned about the level of consultant input on the oncology wards and was concerned that patients are sometimes not seen by consultants for several days. We could not get a second opinion on this.  NB. This was raised through the GMC NTS as a patient safety comment which is being followed through by the Trust and monitored through the Quality Register.

Visit Panel Chair Declaration

This completed report is a true and accurate account of the discussion that I participated in or that were reported to me from this visit.

The key recommendations identified within this report have been identified with good faith.

I can confirm that any areas of significant concern that have a direct impact upon patient safety have been brought to the attention of the relevant Director of Medical Education (or equivalent), responsible Medical Director and Executive Lead for Quality at Health Education South West Peninsula Postgraduate Medical Education.

Chair name:

Dr Nick Withers

Chair educational role:

Head of School for Medicine

Date of signature:

 

 

 

Health Education South West Peninsula Postgraduate Medical Education Declaration

I as signatory on behalf of Health Education South West, Peninsula Postgraduate Medical Education can confirm that the information and associated recommendations provided via this report have been reviewed and deemed appropriate for the purpose as stated.

The recommendations contained within this report have been documented as part of the quality management processes of Health Education South West, Peninsula Postgraduate Medical Education and where appropriate, will be reported to the General Medical Council (GMC) as required.

Name:

 

PPME educational role:

 

 

Date of signature: