Executive summary

Overall, feedback of Child and Adolescent Mental Health Services (CAMHS) resident doctors at the trust highlights a lack of progress in key areas and echoes the disconnect between the experience of learners and educators that was identified in the previous quality intervention. The trust had made improvements in some key areas and a useful update on the improvement plan was presented during the review. However, no CAMHS resident doctors recommended their post, nor would they recommend the service to a friend or family member, and significant concerns remain with the education and service provision of Parkview Clinic (inpatient facility), in particular. 

Positive feedback and areas of improvement since the previous review were shared:

• Resident doctors recognised the vast experience of consultants and the deep psychology provision on offer at FTB and the opportunity to participate in audits and quality improvement activity.
• Trainers held regular sessions together to share knowledge and challenges across hubs, received curriculum and best practice updates, and participated in educational appraisals.
• The Education team held regular postgraduate medical education forums and a resident doctor representative was in place at Forward Thinking Birmingham to monitor the learner experience.
• The Education team had encouraged and fostered good engagement with the wellbeing offer of the trust. There were high levels of awareness and understanding of the role and support offered by the Guardian of Safe Working and the Postgraduate Clinical Tutor.

Learners identified some key areas that need to be reviewed and addressed by the trust:

• Resident doctors reported that fundamental infrastructure issues at Parkview Clinic continued to impede education and training. The inpatient set-up was deemed inadequate and stressful for several reasons that included: low staffing levels, low morale, problems with supply and stock of basic items, lack of appropriate nursing skillmix and an overreliance on junior clinical fellows and locums.
• Resident doctors considered the levels of supervision and consultant presence to be low and not conducive to education and training, which was also highlighted on the previous visit.
• Resident doctors reported that their CAMHS experience would be improved if the caseload was more educationally focused. The proportion of follow-up appointments was very high and not following the CAMHS curriculum and Silver Guide, and this limited the opportunity to manage and learn from new patients.
• Resident doctors advised that the on-call room was not adequate for those undertaking the first on-call rota for Parkview Clinic, and its location meant that rest and recuperation was not possible due to noise and disruption throughout the night.
• Issues existed for those based at Birmingham Community Healthcare who participated in the Parkview/CAMHS first on-call rota. They did not have access to the relevant BWC trust exception reporting system.
• The local induction experience was hindered by IT and system access issues.

The educational governance structures further developed and refined since the previous review, as well as the additional trainer support and enhanced wellbeing offer for resident doctors, has not translated into an improved training experience at Parkview Clinic. 

Based on the review findings, the panel will be recommending this item remains at Intensive Support Framework (ISF) category 2.  A trust improvement plan will be required against the mandatory requirements outlined in this report.  

Review overview 

Background to the review

Concerns were identified regarding training within the Psychiatry specialty of CAMHS at Parkview Clinic through the National Education and Training Survey (NETS) in November 2020. Further to the NETS outcomes, feedback was also shared by resident doctors with the Training Programme Director for the West Midlands in June 2021 regarding reports of concerns within the department in relation to the role, responsibilities and safety of resident doctors working in the service area.

A learner educator meeting was held in April 2022 to assess the environment for resident doctors. Overall, resident doctors reported a suboptimal training experience within CAMHS at Parkview Clinic. There appeared to be a disconnect between feedback offered by doctors in training regarding their experience within the organisation, and the feedback offered by trainers and the Education team regarding their understanding of the concerns being raised. It was reported by resident doctors that they have been managing patients without adequate clinical supervision in place to support them at Parkview Clinic and within the community setting. Concerns were also raised regarding there no longer being sufficient CAMHS consultants in place to provide adequate educational and clinical supervision.

A trust improvement plan was requested after the review, in addition to a further update request in 2023. A follow-up learner educator meeting was arranged for September 2024 to monitor progress and assess the current training environment for CAMHS resident doctors at FTB.

Who we met with

Learners

• CAMHS Higher, Core and Foundation resident doctors

Clinical and Educational Supervisors

• CAMHS Supervisors

Education team

• Postgraduate Clinical Tutor
• Deputy Medical Director (Mental Health)
• Director of Education and Quality Assurance
• CAMHS College Tutor

Review panel

• Head of School (WM Psychiatry), Dr Amitav Narula, Education Quality Review Lead
• Training Programme Director (WM CAMHS), Dr Cameron Shields, Specialty Expert
• NHS England Education Quality Representative (Midlands), Raj Sunner, Quality Manager

Review findings

Education Team

The Education team highlighted actions taken since the 2022 review and their ongoing monitoring of the clinical learning environment. The Education team was satisfied that previously identified issues had on the whole been addressed, except for a few areas that had active plans and mitigations in place. These included IT issues at Parkview Clinic, nursing processes and escalation at Parkview Clinic, issues with clinic room bookings across all hubs, and an ongoing review of the suitability of the on-call room.

The Education team held regular postgraduate medical education forums and a resident doctor representative was in place at Forward Thinking Birmingham to monitor the learner experience. The Education team had encouraged and fostered good engagement with the wellbeing offer of the trust. There were high levels of awareness and understanding of the role and support offered by the Guardian of Safe Working and the Postgraduate Clinical Tutor.

The College Tutor advised that trainers held regular sessions together to share knowledge and challenges across hubs, received curriculum and best practice updates, and participated in educational appraisals.

Induction

The implementation of a local psychiatry specific induction in August 2024 was a positive step taken by the trust since the previous review and was welcomed by resident doctors.

Unfortunately, the induction experience was hindered by IT and system access issues.

Caseload

Resident doctors reported that their CAMHS experience would be improved if the caseload was more educationally focused. The proportion of follow-up appointments was very high and not following the CAMHS curriculum and Silver Guide, and this limited the opportunity to manage and learn from new patients. The issue was further exacerbated by the lack of consultant presence to discuss patients.

Exception reporting

Resident doctors advised that exception reporting was encouraged at the trust, however, issues existed for those based at Birmingham Community Healthcare who participated in BWC’s first on-call rota. They did not have access to the relevant trust exception reporting system. The Clinical team confirmed that they were aware of the issue, and this was being explored.

Parkview clinic infrastructure

Resident doctors reported that fundamental infrastructure issues at Parkview Clinic impeded education and training:

• The inpatient set-up was deemed inadequate and stressful.
• Low staffing levels, low consultant presence, as well as no substantive consultant appointment.
• An overreliance on junior clinical fellows and locums
• Lack of appropriate nursing skill-mix
• Lack of space and IT issues (including the adequacy of laptops and the network)
• Low morale across professions
• Problems with supply and stock of basic items, had led to a challenging environment for all staff.
• Resident doctors and non-training doctors were constantly “firefighting” non-training related issues.

Resident doctors advised that concerns about the inpatient experience at Parkview Clinic have been raised over several years, however, there has been no tangible improvement and a feeling that concerns are not listened to, dismissed and on occasion met with hostility. Resident doctors were aware of past and present quality improvement initiatives but these were deemed as having minimal to no effect.

On-call room

Resident doctors reported that the on-call room was not adequate, and its location meant that rest and recuperation was not possible due to noise and disruption throughout the night. The Education team was aware of recent resident doctor challenges with the on-call room and this matter was being actively explored.

Supervisor presence and accessibility

Resident doctors acknowledged the benefits of working in an environment that encouraged independence and autonomy, however, resident doctors considered the levels of supervision and consultant presence to be low and not conducive to education and training. Supervision was virtual and remote by default. This has become the default due to the lack of appropriate resources, such as, a consultant office or room to undertake one-to-one supervision. The one dedicated hour a week was insufficient and often used for other tasks besides discussing cases. Furthermore, the lack of presence and accessibility of consultants meant that they had at times struggled to obtain advice when needed throughout the week.

The low consultant presence and involvement in training contrasted with the resident doctors experience of other sites, which had greater levels of consultant engagement with day-to-day activity. Resident doctors had resorted to teaching themselves the basic principles and themes across patients but recognised this was suboptimal, and not viable for more complex cases.

Finally, there were specific concerns raised around supervisory capacity for psychotherapy.

Trainers confirmed that they had time in job plans to conduct their supervisory duties and they felt they were accessible to resident doctors. They were not aware that presence and accessibility was an issue for resident doctors. They acknowledged that supervision was remote due to a lack of physical space and no consultant offices further compounded the issue.

Psychology provision, audits and QI

Resident doctors recognised the vast experience of consultants and the deep psychology provision on offer at FTB and the opportunity to participate in audits and quality improvement activity.

Areas that are working well  

Areas for improvement

Mandatory requirements

Report approval

Report completed by: Raj Sunner, Quality Manager (Midlands)
Review lead: Dr Amitav Narula, Head of School (WM Psychiatry)
Date approved by review lead: 25 October 2024

NHS England authorised signature: Prof. Andy Whallett, West Midlands Postgraduate Dean Date authorised: 25 November 2024

Final report submitted to organisation: 24 January 2025