Postgraduate School of Psychiatry Quality Management Visit to Plymouth Community Healthcare

 

2nd July 2014

 

 

Postgraduate School undertaking visit: Psychiatry

Primary author of report (name and job title): Dr Kate Lovett Head of School Psychiatry

Local Education Provider visited: Plymouth Community Healthcare (PCH)

Visit team (names and educational job titles)

Chair

Dr Kate Lovett

Panel member 1

Dr Giles Richards Training Programme Director (General and Old Age Psychiatry)

 

Panel member 1

Carla Miners School Manager

 

Ley representative

Kitty Heardman

 

Programme / Specialty

No. of trainees seen

No. of trainers seen

Psychiatry

5 Core trainees - CT1/2 and 3 trainees and a locum appointee. 2 Higher trainees – 1 in Old Age/Adult and 1 CAHMS

5

Evidence considered prior to review taking place: GMC Trainee survey 2013; LEP Visit Report 2011

Date visit report ratified by SWPPME

17.8.14

Date visit report made available to provider

18.8.14

Date provider ratifies visit report

12.9.14

Circulation of this report: PPME Quality Team, PCH Director of Medical Education, PCH Medical Education Manager

 

Executive Summary

 

Plymouth Healthcare Community Interest Company is a social enterprise (not for profit company) which was established  in October 2011, to provide NHS health services previously provided by Plymouth Primary Care Teaching Trust.  As well as providing non GP out of hospital community services it provides inpatient and community mental health services to children and adults.

It has a well-established psychiatric training scheme which currently provides training to 7 Core Trainees, 3 GP VTS trainees and 2 F2 doctors. In addition it provides higher training posts to up to 4 trainees in old age/general psychiatry and to up to 3 higher Child and Adolescent mental Health Trainees.

There is currently no designated Director of Medical Education within Plymouth Healthcare. This role is subsumed by the recently appointed acting Medical Director, Dr Andy Sant. The College Tutor is currently Dr David Bickerton. This post has recently been advertised prior to his forthcoming retirement.

This visit was the first re-visit to the Plymouth Psychiatric Training scheme since the establishment of Plymouth Healthcare. The previous report in 2011 identified the need to establish a psychotherapy tutor, increase expectation of the number of case conferences journal clubs trainees were undertaking, establish a robust system for handover, establish a mechanism for communicating concerns from the tutor re. doctors in difficulty to new supervisors, and involve service users in developing the local teaching programme. These have been actioned.

Feedback from the GMC Trainee survey 2014 is currently awaited. Early results indicate no major concerns with psychiatric training in Plymouth.

FEEDBACK FROM PLYMOUTH HEALTHCARE

The panel met with the Chief Executive, Mr Steve Waite, Mrs Teresa Duggan, Medical Staffing Lead, Dr Naresh Buttan and Dr Alison Battersby, senior consultant psychiatrists who were in attendance in the absence of the College Tutor and Medical Director due to planned annual leave.

Plymouth Healthcare has met the challenges of staff recruitment since becoming a social enterprise and there is a well-established corporate induction programme for all staff as well as additional induction for psychiatric trainees and local team induction. Trainers have established SPA (Supporting professional Activity) time within job plans to attend the academic teaching programme with trainees. The inpatient psychiatric unit at the Glenbourne site is shortly due to be refurbished. Plymouth Healthcare has introduced a street triage programme to impact on the high numbers of Mental Health Act Assessment requests in the city.

The challenges of covering the duty rota for junior doctors was acknowledged. This has been due to sickness absence and maternity leave and a lengthy recruitment process for locums. It had led to senior doctors “acting down” recently. Senior trainees had however been given a choice in this and been appropriately   remunerated  for additional work. It was acknowledged that even when fully staffed, the rota for trainees was frequent and the shift system took trainees away from routinely scheduled work within their placements.  The additional strain of covering absence had exacerbated this.

In addition to fulfilling their educational supervisory roles locally, trainers had been supported by the organisation to take part in wider educational activities, such as supporting Royal College of Psychiatrists’ initiatives; promoting recruitment, careers fayres and Deanery ARCP( Annual Review of Competency Progression) and recruitment panels. Trainers reported that some trainees who had come to Plymouth Healthcare to undertake Foundation and GP  VTS (vocational training scheme)  training had subsequently gone on to  pursue careers in Psychiatry following positive placements.

 

 

Dr Kate Lovett

Head of School for Psychiatry

 

 

 

Key recommendations

Ref

Department / Programme / Specialty

Key recommendation(s)

1

 

A clear system for day-time senior psychiatric cover for the on-call rota should be established and communicated to junior doctors. Immediate action required.

 

2

 

Concerns regarding communication between the Home Treatment Team and junior doctors should be brought to the attention of the Team Manager and Medical Director in order to resolve the current difficulties.  Immediate action required.

 

3

 

Plymouth Healthcare should work with Plymouth Hospitals NHS Trust to establish safety of psychiatric patients waiting in CDU (Clinical decisions Unit) lounge for further assessment.  Immediate action required.

 

4

 

It will be important to develop strong psychiatric educational leadership within Plymouth Healthcare . In the absence of a Director of Medical Education both the new College Tutor and Medical Director should be supported in their job plans to attend the quarterly School Board meetings

3 months

5

 

Trainers should be supported via peer support and the appraisal process to consider their own educational development and in particular to be clear in their own roles and those of others in identifying and supporting doctors in difficulty.

12 months

6

 

The College tutor should ensure that all trainees participate in the ECT rota in order to demonstrate curriculum competencies in administering ECT

3 months

7

 

A liaison supervision group should be re-established

3 months

8

 

The academic programme should be strengthened with clear leadership and expectations of involvement of senior and junior doctors

3 months

9

 

The current deficit in providing CBT training should be addressed. This may need to include an arrangement with the IAPT (Improving Access to Psychological Therapies) service.

12 months

10

 

Plymouth Healthcare should consider their policy re.contacting trainees on leave/off duty re. requests to provide cover

3 months

 

11

 

Whilst not a direct educational matter, Plymouth Healthcare should review facilities available to on-call junior doctors including access to refreshments and clinical IT.

3 months

12

 

Information regarding regional peer support for higher trainees should be communicated to Medical Staffing from Training programme Directors for inclusion within the induction pack

 

Areas of good practice

Department / Programme / Specialty

Area(s) of good practice

 

1

Well established induction programme. Trainees described receiving high quality teaching and explanations of on-call systems, mental health act, safety etc when they started in the LEP. In addition they described  a clear process for team induction.

 

2

Well established culture of clinical and educational supervision with protected time for weekly 1;1 supervision with educational supervisors.

 

 

Summary of the visit

Patient safety inc. handover and induction

  • Trainees described a robust system for induction at a corporate, departmental and team level as described above.

 

  • Trainees described a well-established system for face-to-face handover between junior doctors between on-call shifts which included discussion of any outstanding referrals, handing over relevant clinical information and included handing over a duty log which documented calls received.

 

 

Supervision – clinical and educational (inc. career guidance, feedback)

  • Trainees described having protected time for high quality educational supervision which was held 1:1 on a weekly basis. They commented on the positive attitude of their trainers and a well-established culture which valued supervision.

 

  • Trainees felt appropriately supported by their educational and clinical supervisors and did not feel that they were being asked to undertake tasks beyond their level of competency.

 

  • Trainers generally considered that they had time job-planned for supervision and attending the academic teaching programme.

 

  • Higher Trainees reported excellent supervision, appropriate clinical experience and opportunities to obtain leadership, special interest, research and teaching competencies.  Both trainees had moved from other Deaneries and they had not had the opportunity to meet with other higher trainees. They told the panel that they would have appreciated earlier contact details for the higher trainees peer groups.

 

 

Department / Programme / Specialty

Area(s) of development

 

  • Trainees described that there was no designated on-call consultant between 9am -5pm when CT1-3 doctors were on a duty rota. They described it sometimes being difficult to obtain senior advice due to lack of clarity re senior responsibilities. Some trainees gave examples of waiting until 5pm in order to contact the on-call consultant for advice with the result that patients had waited in Derriford Hospital during the day for a final decision about their care pathway. Some trainees described obtaining advice from their educational supervisor when available and others contacting consultants in other organisations for advice when it was an out of area patient (eg from Devon or Cornwall). Trainees described that they felt the process for obtaining senior advice during the daytime was unclear. Although they generally had obtained support and advice they described that it was sometimes a lengthy process in accessing this.

 

  • The panel noted some ennui and disengagement of some of the trainers when they met with them separately. They were clearly under clinical pressure but described being unclear about current educational processes including the role of the Deanery and links with their own tutor and systems for supporting trainees in difficulty. There has not a clear process for educational peer support and development historically although the panel learnt that it was planned to resurrect the clinical practice meeting with trainees and to create a separate peer supervision group for trainers on a three monthly basis.

 

  • Some trainers described concern that not all trainees were participating in the ECT (electroconvulsive therapy) rota and did not appreciate that this was an essential part of their training

 

 

 

Training environment (inc. access to educational resources

1)      Trainees felt that it was they were generally supported and it felt safe to express their clinical opinions

 

Department / Programme / Specialty

Area(s) of development

 

  • Core Trainees described an uneasy relationship with nursing staff from the Plymouth Home Treatment Team (HTT)

a)      They described that they felt clinically undermined at times when they had identified situations which they felt warranted home treatment/crisis support but that the threshold for accepting patients by  the home treatment team was focussed solely on level of risk

b)      The trainees described that they were regularly not told about admissions arranged by the Home Treatment team and usually only found out a few minutes before the patient arrived on the ward from ward staff. They felt that it would be helpful and safer to have a direct handover from Home Treatment Staff from the community.

c)       Trainees described that it was not easy to persuade staff from Home Treatment Team to attend assessments out of hours which frequently lead to patients waiting overnight in A+E until the morning. They described that there was a HTT on call system but that practitioners were reluctant to come out in the middle of the night as they were working during the day also.

d)      Trainees described that on occasions they had been concerned about patients they had already assessed waiting in the clinical decisions unit (CDU) lounge at Derriford Hospital for assessment by home treatment team because they felt this environment was poorly supervised. They described an incident whereby a patient had put a wire around their neck and another where a very distressed patient had to wait unsupported for several hours.

 

 

  • Trainees described that previously provided tea and milk in the doctors’ on-call room had recently been withdrawn due to budgetary cuts. Whilst not directly an educational issue, access to refreshment whilst on an overnight shift will have an impact on the overall learning culture of an organisation.

 

  • Trainees described that there are currently two computers in the on-call room. However they told the panel that 1 does not work and the other is incompatible with the new Trust IT system which is due to be introduced in 2 weeks’ time. It will be important to ensure that doctors on shift have access to functioning IT systems in order to access clinical notes and update these in a timely fashion.

 

 

Work load

  • The Trainees described generally feeling supported by human resource department although they described that on occasions they felt their home/life boundaries had been intruded upon when contacted off duty/on leave to be requested to cover additional shifts due to sickness absence etc.

 

Department / Programme / Specialty

Area(s) of development

 

  • Trainees described that they had felt their home/work boundaries encroached upon at times. They had found this particularly frustrating especially when it was clear that because of existing rota arrangements it would not be possible for them to do extra shifts.
  • Trainees described a delay in finding out where their next rotational posts were. They were currently waiting to find out this information despite the rotational change being in less than 1 month. Ideally they stated that they would like to know their rotational placements for the following year in advance.

 

Adequate experience / achievement of curriculum competencies

  • They had no difficulties in completing Workplace Based Assessments

 

Department / Programme / Specialty

Area(s) of development

 

  • Trainees described that the academic programme had been poorly coordinated in the past with inconsistent standards and attendance. They felt that this had improved over the last few months but were not clear who was responsible for its organisation.

 

Teaching – local, regional and study leave

  • They described having protected time to attend the MRCPsych Course and were generally freed up from clinical duties to attend. The only time when this was not the case was when they were on duty. They described that the frequency of the rota meant that they could potentially miss a significant number of course days throughout the course of the academic year and that it was difficult to find colleagues willing to swap.
  • Trainees described that they had not had any difficulties in taking study leave.
  • Trainees described that  the liaison supervision group  previously  run by Dr Cant was reported as being valued by trainees but had not been replaced after he left in 2013. This was a weekly supervision group in which trainees had the opportunity to present on-call clinical cases in detail to the group with expert feedback regarding formulation, diagnosis, risk assessment and management plans.

 

 

Department / Programme / Specialty

Area(s) of development

 

  • Trainees and trainers confirmed that there was no access to Cognitive Behavioural Psychotherapy training for Core Trainees and for general and old age higher trainees. Trainees were concerned that this detracted from the breadth of psychotherapy experience available. This is currently limited to counselling and psychodynamic psychotherapy.

 

Undermining, bullying and harassment

 

 Nothing to report

Additional comments / feedback

Grateful thanks are extended to Plymouth Community Healthcare for hosting the School of Psychiatry LEP visit. Particular thanks are extended to Chief Executive, Mr Steve Waite, Mrs Teresa Duggan, Medical Staffing Lead and Drs Buttan and Battersby for representing the College Tutor and Medical Director. Acknowledgements are made to the trainees and trainers who made time to meet with the panel. Many thanks to Claire Bell and Teresa Duggan for their organisation of the visit and ensuring smooth running of the day. Thanks you  to Dr Giles Richards and Kitty Heardman for providing externality to the visit. Final thanks to Carla Miners and Maria Clace from Health Education SW for their liaison and administrative support.

 

 

 

Visit Panel Chair Declaration

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

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

I can confirm that any areas of significant concern and that have a direct impact upon patient safety has 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 Kate Lovett

Chair educational role:

 

Head of School for Psychiatry

Date of signature:

 

August 2014