Executive summary

This Senior Leader Conversation focused on postgraduate medical training within Respiratory Medicine at Darent Valley Hospital, Dartford and Gravesham NHS Trust. This quality intervention was arranged in response to concerns raised via the Kent, Surrey and Sussex (KSS) Foundation School regarding the clinical learning environment within Respiratory Medicine, which were triangulated with a significant deterioration in the 2024 General Medical Council National Training Survey (GMC NTS) results. The panel met with Trust board, medical education, divisional and department leadership representatives to explore the concerns.

It was recognised there had been significant concerns regarding the availability of senior support and supervision for Foundation doctors on the respiratory ward on weekdays. Contributing factors were reported to include specific senior staffing arrangements and diversion of senior medical staffing to outpatient work and respiratory patients elsewhere in the hospital.

In contrast, the support provided by substantive consultants at weekends was noted to be good.

The Trust were encouraged to consider the feasibility of ensuring job planned substantive consultant presence on the respiratory ward on weekdays. The ongoing challenges with substantive respiratory consultant recruitment were discussed and the panel heard this would be an area of focus for the Trust. The panel recommended that the Trust consider how exit interview feedback from senior Higher Specialty doctors in training could inform this work.

The panel concluded that the adequacy of weekday clinical supervision and support for Foundation doctors on the respiratory ward will require further monitoring and issued one mandatory requirement in relation to this. The panel will require assurance that respiratory consultants are consistently able to physically attend the respiratory ward on weekdays between 09:00 – 17:00 to support doctors in training in seeing and managing patients. An education quality focus group with doctors in training in Respiratory Medicine will be arranged in early 2025 to review progress.

Review overview

Background to the review

This Senior Leader Conversation was triggered by concerns raised via the Kent, Surrey and Sussex (KSS) Foundation School regarding the clinical learning environment within Respiratory Medicine, triangulated with a significant deterioration in the General Medical Council National Training Survey (GMC NTS) results this year.  

Who we met with

• Chief Medical Officer
• Deputy Chief Executive Officer
• Clinical Director of Medicine
• Acting Divisional Director for Medicine, Cancer and Emergency Medicine (MCEC)
• Respiratory Consultant
• Director of Medical Education
• Medical Education Manager

Review panel

• Miss Alison Crocker, Associate Dean (Education Quality Review Lead)
• Professor Nik Patel, Head of School of Medicine
• Dr Paul Reynolds, Head of Foundation School
• Martin Brand, Lay Representative
• Nicola Trower, Education Quality Support Administrator (Scribe)     

Review findings

The Clinical Director presented an overview of the Respiratory Medicine service, noting that the respiratory ward (Palm ward) is one of the largest medical wards in the hospital and has faced challenges since the COVID-19 pandemic, including a reduction in the number of substantive respiratory consultants, whose clinical time had been focused on outpatient work as part of the lung cancer pathway. The panel heard that eight locums, all without Certificate of Completion of Training (CCT), had been employed to provide ward cover since 2022. Despite the challenges described, the Trust felt that the department had provided a good educational experience until November 2023, citing previous General Medical Council National Training Survey (GMC NTS) results as evidence of this. An overview of the actions taken to address concerns highlighted by the 2024 GMC NTS results for Respiratory Medicine was provided; further details are outlined under the relevant domains of this report.

Domain 1: Learning environment and culture

Teamwork and supportive environment

The panel heard that the number of resident doctors in the department had increased to 10, consisting of three Foundation year one (F1) doctors, three Foundation year two (F2) doctors, three Internal Medicine Training (IMT) doctors and one Trust grade ‘SHO’. It was explained that the number of ‘registrar’ level doctors had increased to three and the intention was that one ‘registrar’ level doctor would be present on the ward at any one time. The Trust perceived that the increase in numbers would help to improve the overall experiences of doctors in training in the department.

The panel heard that ‘Hospital at Night’ was relaunched around three months ago. It was explained that experienced site practitioners were involved in bleep filtering and this initiative helped to support doctors out of hours.

The panel were aware of concerns regarding interactions between the Emergency Department (ED) and other specialties within the hospital. The Trust outlined the pathway for medical patients admitted via the ED. It was reported that if a specialist respiratory opinion was required for a patient in the ED then this would be sought, however there was not a named consultant for this.

In terms of relationships between specialties, the Trust perceived that problems could arise where there is a lack of clarity around referral pathways and explained that work was underway at a divisional level to ensure greater clarity around referral pathways, alongside a civility training programme.

Handover

The panel heard that improvements had been made to handover arrangements; handover was now consultant-led and was shorter in duration, while providing a valuable learning experience for resident doctors. It was explained that handover had been audited to demonstrate improvement.

Domain 2: Educational governance and commitment to quality

The panel heard that the Trust had identified concerns regarding education and training experiences in the department prior to the release of the 2024 GMC NTS results, via an internal survey prior to the Local Faculty Group (LFG) meeting in June 2024. Following this, the Director of Medical Education had met with the resident doctors in July 2024 to explore the concerns and the findings were presented to the LFG. The panel understood that, due to this internal process, the 2024 GMC NTS results had not been a surprise to the Trust. The panel heard that conversations were underway to consider how staff survey and patient feedback could be triangulated with feedback on education and training to develop a more uniform understanding of potential issues.

Domain 3: Developing and supporting learners

Clinical supervision

The timeline of concerns around senior support and supervision on the ward in relation to changes in senior locum staffing was discussed. It was recognised that there had previously been a lack of clarity around patient ownership, which had impacted on handover, as well as lack of support and supervision for Foundation doctors on weekdays. The Trust explained the timeline of events and assured the panel that the current senior staffing arrangements were expected to lead to improvement, adding that informal feedback had already indicated an improvement. The Trust confirmed that two consultants were now present on the ward each day for the morning ward round and were allocated to be available on the ward between 09:00-17:00.

In contrast to concerns about senior support on weekdays, doctors in training had reported they felt well supported at weekends, as substantive consultants were available on the ward. It was recognised that since the pandemic, a significant amount of the substantive respiratory consultants’ clinical time has been focused on the lung cancer pathway, which, although clinically appropriate and done with good intentions, has further impacted on ward cover and support for doctors in training on the ward. The Trust were encouraged to consider the feasibility of ensuring job planned substantive consultant presence on the respiratory ward on weekdays. The panel emphasised the importance of ensuring ward work received the same recognition as outpatient work within consultants’ roles. See mandatory requirement reference RESP-MR1.

The panel had also received feedback that respiratory patients stepping down from ITU to Laurel ward were mostly managed by the renal team with support from outreach and respiratory nurses; the respiratory registrars cover these patients if additional support is required and although this was rare, when this did happen it further impacted senior presence on Palm ward.

The panel shared feedback that ‘registrar’ level resident doctors spent a significant amount of time away from Palm ward looking after respiratory outlier patients, which impacted the amount of support they were able to provide to Foundation doctors. The Trust acknowledged this feedback but felt this required further exploration, as it was not perceived to align with the Trust’s current understanding of the situation. The Trust confirmed there was ongoing work within the Medicine division to ensure that patients were accommodated on appropriate wards according to their clinical needs.

The panel heard that despite the concerns raised around a lack of senior support on the respiratory ward, doctors in training had been able to go to the respiratory office to obtain support and did not perceive that patient safety had been compromised. In terms of reporting systems, the panel heard that both the department and directorate acknowledged the need to update resident doctors on actions taken when concerns are reported.

Induction

The panel heard that the induction handbook had been updated by the department.

Domain 4: Developing and supporting supervisors

The Trust explained that there had been changes in the allocation of Educational Supervisors to ensure that doctors in training were spread more evenly across supervisors, in order to allow more time for training.

The panel heard that all supervisors were reported to have the correct amount of time allocated in their job plans, however a survey was underway to understand whether supervisors have specific job plans and whether they are able to use the allocated time for supervision. Specifically with regards to respiratory medicine, the respiratory consultant present reported they had not encountered any problems with time for educational supervision.

The panel heard that an Educational Supervisor forum took place three times per year, although it was recognised that these may not capture those who are less engaged with educational activities and the Medical Education team were considering alternative approaches, such as delivering training at departmental meetings.   

It was confirmed that educational appraisal forms part of the Trust’s formal appraisal process and the new software for appraisal includes an education page. The panel heard that Educational Supervisors have the opportunity to utilise the 360-assessment tool and funding has been confirmed for this to continue over the next year.

Domain 5: Delivering programmes and curricula

The panel heard that the departmental teaching programme had been reinvigorated; practical ‘hands-on’ teaching was now scheduled during ward rounds, in addition to the teaching which took place on Friday afternoons in the education centre. The panel were informed that Friday teaching was led by registrars, however all consultants participated in teaching. Data showing an improvement in F1 and F2 attendance at teaching sessions was presented.

In terms of regional teaching, it was reported that attendance is expected and promoted, and provisions are made to allow doctors in training to attend. The Clinical Director reported that the directorate were proactive in granting study leave.

In response to a question, the DME confirmed that a previously recognised issue with availability of rooms for education and training had now been rectified and no training had been cancelled due to lack of room availability.

Domain 6: Developing a sustainable workforce

The panel heard that recruitment of substantive respiratory consultants within the Trust had been, and remained, challenging. There was a perception from within the department that this may be related to underinvestment in the respiratory service at DGT, for example the Trust does not have a sleep service, which may make consultant posts less attractive to prospective candidates. However, it was acknowledged that it is not possible to ascertain why people have not applied. The panel encouraged the Trust to consider exit interview feedback from higher specialty doctors in training who did not intend to work in the Trust following completion of training. See recommendation reference REC-1.

The panel heard that the department had successfully appointed a respiratory consultant in September 2024, who had previously worked in the department as a locum. Furthermore, it was reported that six consultants had been recruited across the medicine directorate in the past year, although it was recognised that more respiratory consultants were needed. The Chief Medical Officer (CMO) reported that there would be a focus on the respiratory department in terms of recruitment and there is a commitment to advertise three posts. The CMO added that to their knowledge no service development proposals had been received from the department in recent years, but the Trust were open to developing services which would benefit patients.

Areas that are working well

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Sarah Stanbridge, Education Quality Project Officer
Review lead: Miss Alison Crocker, Associate Dean
Date approved by review lead: 20 October 2024

NHS England authorised signature: Professor Jo Szram, Postgraduate Dean
Date authorised: 23 October 2024

Final report submitted to organisation: 15 November 2024