FOUNDATION TRAINING QUALITY MANAGEMENT VISIT TO IPSWICH HOSPITAL NHS FOUNDATION TRUST VISIT REPORT Visiting Team: Trust Team: Number of trainees met: DATE 04/03/2015 Professor John Saetta - East Anglian Foundation School Director Dr Jeremy Chase- Foundation Training Programme Director West Herts Mark Bullock Foundation School Coordinator Dr Vera Saulite Trainee Representative Dr Barbara Buckley - Medical Director Mr Robert Brierly - Director of Medical Education Mr Tim Brammar- Foundation Programme Training Director Ms Mary Burgess - Medical Education Manager Ms Kay Wilson - Medical Education Facilitator Ms Sandy Phillips - Foundation Programme Administrator Foundation Year 1: 22 [including Medicine, Surgery, Psychiatry, T&O] Foundation Year 2: 24 F2 [including Medicine, surgery, O&G, GP, psychiatry, Paediatrics, Oncology, Pathology] Purpose of visit : The purpose of the visit was to review and monitor the educational agreement between the Trust and Health Education East of England (HEEoE), and to quality manage the Foundation Training on behalf of Health Education East of England (HEEoE), in accordance with the standards for Foundation Training set out by the GMC in The Trainee Doctor (2011). This visit was undertaken as part of the third cycle of Quality Management visits for Foundation Training across the East of England. The visit commenced with a welcome and introductions. Meeting with the Trust Team : The visiting team thanked the Trust s Education team for organising the visit. Introductions were made and the purpose of the visit was outlined. Professor Saetta clarified that any patient-safety concerns which may arise during the course of the visit would be shared with the Trust and would require appropriate action. The following areas were then discussed: 299 bleep - The Trust advised they were working hard to improve this. All members agreed that this is fundamentally an issue of resource. The higher number of colorectal trainees against those of other surgeries is the main factor and in an attempt to resolve this, the Trust moved to a ward-based system to try to achieve a more even distribution of workload. It was added that this change in system has been favourable to some but not to others, as with any change. Workload - The Trust advised that there will undoubtedly be workload concerns fed back by the trainees. On a positive note it was fed back that workload for surgery was a green outlier in last year s GMC Survey. The Trust is looking to increase medical presence to continue to improve medical out-of-hours workload. This will include additional cover on weekends and evenings. Between 10pm-7am there is one registrar and two juniors on the Page 1 of 5
wards and it was asked if there could there be an additional registrar. The Trust team responded that it was a struggle to fill the registrar posts with candidates of an acceptable standard. The Trust is currently reviewing unbanded posts to see if they can spread some of the workload. In addition, there are currently a number of CST s (Clinical Support Technicians) working within AMU and A&E and also one in Lavenham Ward who provide support such as phlebotomy. There is also clinical outreach provided from ITU for patients with low immunity systems. However, it is support for those patients who are not as sick where the real struggle lies. There is a new electronic system to be launched where each junior doctor and nurse will have an ipad Touch as a means for more efficient communication and prioritisation of handling of workloads. These are also used to access patient records. If this would be to fail, teams would need to revert to paper-based systems in order to access patient records. The Trust currently works between the two systems and hopes to progress this further as soon as possible. Psychiatry - The team discussed Psychiatry which the Trust confirmed is on site although a number of trainees go out on community visits, particularly those working in adolescent Psychiatry. It was agreed that the first F1 post in Psych is usually a problem as it takes the trainee out of the Acute Trust for 4 months, an issue not confined to Ipswich. Ipswich has started to implement a system where these trainees spend more time at the Trust during this placement so that they do not feel as overwhelmed when they commence their second post which will be 100% hospital-based. The current Pathology post carries the same issue for some trainees. ED Handover Issue - The Trust advised that the department was asked for action plan to address GMC survey feedback and are positive that this has been addressed. There is a staggered changeover and it was recommended to the Trust team to consider the 8 o clock handover as implemented by some other Trusts. The Trust do not feel that there are any issues with Friday evening s movement of patients from AMU and they don t view this as any different than any other night. Undermining: There was an instance of undermining by a Consultant which the Trust confirmed is now subject to formal processes. There was also an instance of undermining from a registrar which the Trust has confirmed to have been addressed. On a positive note the GMC visited Ipswich to review good practice in relation to undermining in O&G. Educational Supervisors (9) General Feedback Educational Supervisor time is not factored into individual job plans form several supervisors and all agreed that there needs to be more consistency among CDG s. There are around 30 Educational Supervisors who have regular meetings with support from Kay Wilson and Sandy Phillips. This is a forum to discuss issues and solutions and includes trainee representation. Current supervisors must undertake an e-learning package in order to work in the role although they are currently unclear as to when they need to take a refresher on this. The supervisors extended their gratitude to Tim Brammar, Sandy Phillips, Kay Wilson, and Mary Burgess in their organisation of trainees and their portfolios which assists them greatly in their supervisory roles. They also feel that trainees in difficulty are looked after by the postgraduate team to a commendable degree. The visiting team also reminded the supervisors of HEEoE s role in assisting with trainees in difficulty. Recruitment to posts -The F1 reserve list process was explained to the educational supervisors who feel that gaps in Page 2 of 5
Foundation posts causes a lot of issues. HEEoE also advised that we need to know about F2 vacancies in order to place out of sync trainees before allowing Trusts to fill with LAT/S doctors. Psychiatry - There is a shared concern that trainees in Psychiatry at F1 level are in an observatory role which is equal to that of a medical student. There has been feedback from trainees that Psychiatry is more suitable for an F2 role. The Foundation School responded that we are responsible for posts and would not promote posts which are not working. Strengths: Supervision during the day was reported to be good for all specialties other than Upper GI and Colorectal surgery. Vascular surgery supervision was held up as particularly excellent. One trainee in Psychiatry reported very good supervision with a consultant and registrars support at all times. The new ward-based system in the daytime works better for spread of workload and efficiency. Handover in Medicine was highlighted as very effective. None of the F1 or F2 trainees have been asked to prescribe cytotoxics. The majority of trainees felt that they were able to achieve their competences throughout the year with good learning on the job experience. There are some useful teaching sessions offered to both F1 and F2 trainees. These are also completely bleep free. The Postgraduate Team were highlighted as excellent by all trainees, particularly Sandy Phillips and Kay Wilson. F1 doctors reported that they had not experienced any undermining or bullying during their time at the Trust. All trainees felt that there was good opportunity to obtain feedback from their supervisors. All trainees felt that departmental induction has been delivered and was effective. Many trainees remarked that the support from outreach and other seniors is excellent. Tim Brammar was held up as exemplary in T&O. Additional feedback in relation to Psychiatry was that it is more beneficial at F2 level as you are able to clerk patients. Some also felt that while four months seems too lengthy in Psychiatry, all trainees would benefit from a short exposure to it. Of the trainees met all but one would recommend their current post and the Trust to a friend. Page 3 of 5
Areas for Development: F2s reported that supervision in Colorectal Surgery is variable. One trainee struggled to reach the registrar in Surgery at night. All trainees fed back that weekend supervision was often affected by workload. Several F1s reported that the amount of work in Surgery against the available staff causes a significant issue. While CSTs are available, they are also extremely understaffed so trainees often take bloods themselves. Both groups of trainees reported that there is no formal weekend handover in surgery. Trainees working in Psychiatry feel that the work is largely observatory duties. There was a joint agreement that there needs to be more involvement in mental health care management. There was also feedback suggesting that the ward-based system is ineffective for Foundation Doctors due to a constant moving about meaning there is no continuity of patients that they see and treat. All surgical F2 trainees fed back that the General Surgery rota is exhausting. Several trainees elaborated that surgery is almost a service post, without effective support. In addition the communication between consultants and juniors is extremely poor. Another F2 reported that the current A&E rota is extremely severe and would benefit with a review. There were significant patient safety issues raised by both groups of trainees who feel that that there have been several critically ill patients left to get worse when they should have been seen: An F1 in Surgery reported an extremely sick patient, picked up by chance, who had not been seen in 1-2 Days. A patient with Liver hepatic abscess had not been seen for several days- a current F2 felt shunned by the registrar when she asked for help with the patient. The patient subsequently died leaving the F2 to explain this to the family. A patient with cholecystitis was not seen for several days although the F2s noted that the responsibility of the care was not entirely surgical and that ITU was involved in the patients care. Two F1 trainees were asked to consent but responded that this was not appropriate and so this was undertaken by a doctor of the correct grade. Several surgical F2 trainees were asked to consent and refused. One F2 trainee in T&O was asked to consent for procedures he was not trained to provide and complied several times on the same day. Both groups of trainees found teaching to be variable and all noted there is not any significant teaching in Upper GI/Colorectal Surgery. A number of trainees advised that it could be difficult to complete their eportfolio due to lack of assessment opportunity while working. There were a few concerns shared by the F2s that the on the job training was not as effective as it could be and that they felt they had not progressed as far as they would have liked. The F2s were concerned about an ED consultant who has already been reported for undermining/bullying. The group were assured that this consultant s behaviour is being dealt with formally by the trust. Page 4 of 5
Significant Concerns: The issues highlighted in Surgery must be addressed as a matter of urgency, with particular attention to the patient safety concerns raised by both groups of trainees. The feedback received by the visitors will be shared with the Head of School for Surgery. Requirements: 1. The issues in Surgery in relation to patient safety, supervision, workload and handover must be addressed as a matter of urgency 2. Conduct a review of the current A&E rota, taking into consideration a more humane spread of shift patterns to cater for the biological clock 3. Address trainees concerns related to F1 Psychiatry posts and their seemingly inadequate educational experience in mental health 4. Review the teaching programme offered in Surgery In view of the issues with Upper GI and Colorectal Surgery that have been raised unanimously by the Foundation doctors, HEEoE shall expect that the above requirements are acted upon and solutions found to improve the educational value and milieu of the posts. It shall be the intention that HEEoE will pay a focussed re-visit to the Trust, with the School of Surgery, to further enquire into the training of Foundation doctors in these specialties within 6 months of the last visit. Foundation training in these fore mentioned disciplines will only be approved for 6 months pro tem. 5. Recommendations: 1. Conduct a review of CDG s for educational supervisors 2. Ensure educational supervisors are aware of the timeframes in which to refresh elearning modules 8. Conclusion: The visit was concluded with thanks to the organising team for their preparation for the visit as well as the recognition of the support provided by the Medical Education Centre and the work undertaken by the FTPD, the Director of Medical Education and the educational faculty in the delivery of Foundation training. Timeframes: Action Plan to be 1 st October 2015 received by: Revisit/Next A combined Foundation and Surgery revisit is to be arranged at the soonest Visit: convenience, within 6 months. Subject to a satisfactory action plan, the next Foundation visit will be in mid- 2018. Professor John Saetta, Foundation School Director, Health Education East of England Date: 31/03/2015 Page 5 of 5