Executive summary

Overall, obtaining a good training experience has proved difficult for the majority of trainees present at the visit. Several issues were identified during the review, including the following potential patient safety concerns:

• Clinical assessment scores: Clinical assessment scores (Minimum Data Set Questionnaires) being changed and overwritten downstream to facilitate entry into a specific pathway.
• Mandatory training: No consistency in delivery of mandatory safeguarding and risk management training across consortium providers.
• Supervision: Instances of relatively new and inexperienced trainees triaging and managing complex cases (e.g. PTSD) and being required to handle high risk patients with minimal or no supervision and support.

Positive feedback:

• Cognitive Wellness: The provider, Cognitive Wellness, delivered a positive training experience with effective supervision, flexibility, and well-paced learning opportunities.

Key areas that need to be reviewed and addressed:

• Client suitability: Trainees being asked to work with clients whose difficulties were too complex and beyond the curricula. This lack of appropriate clients caused several trainees to fall behind on their expected clinical hours shortly after starting.

• Escalating concerns: Some providers did not support trainees’ needs when concerns were escalated, and some supervisors discouraged raising concerns. As a result, trainees relied on their Higher Education Institute (HEI) for support.
• Placements and learning opportunities: Overall, placements were considered disorganised and unstructured, with trainees nearing completion without appropriate curriculum coverage, e.g., shadowing opportunities.
• Induction: Inductions were deemed disorganised and ineffective, with inconsistent delivery of mandatory training, a lack of preparedness, minimal support from providers, and slow onboarding.
• Service provision and caseload: Trainees felt overwhelmed by the volume of patients and reported inadequate preparation and support from providers.

The above concerns are based on feedback received in relation to the following consortium providers: Our Roots, Health Exchange and St Martins to differing degrees. However, not all consortium members were represented during the trainee session and the consortium should review all providers to understand the full scale of these issues.

There is a noticeable disconnect between the perspectives of supervisors and the LWC central team and the experiences of trainees in the programme, particularly regarding support and supervision, induction, and escalating concerns.

NHS England acknowledges the consortiums efforts to balance provider autonomy, delineate key responsibilities, and ensure delivery through an ongoing audit programme underpinned by a minimum standard framework. However, further work and potential rebalancing are needed to improve the training experience and to better understand the barriers preventing consortium members from delivering a suitable training environment. Additionally, the culture and avenues for escalating concerns needs review, especially feedback regarding supervisors discouraging escalations, as trainees have reported raising concerns previously without resolution.

Based on the review findings, it will be recommended that this item is escalated from an Intensive Support Framework (ISF) category 1 to an ISF category 2.  A Trust improvement plan will be required against the mandatory requirements outlined in this report.

Review overview

Background to the review

An exploratory meeting was arranged with trainees and supervisors in adult mental health and children and young people’s services delivered by the Living Well Consortium to explore and better understand the training environment following concerns raised in relation to supervision and caseload.

Who we met with

Learners

• Trainees in adult mental health and children and young people’s services (high intensity, psychological wellbeing practitioners (PWP) and children’s wellbeing practitioners (CWP))

Clinical and Educational Supervisors

• Supervisors in adult mental health and children and young people’s services

Senior team

• LWC central oversight team (HR Lead, Trainee champion, Clinical Director and Clinical Lead).

Review panel

• Mental Health, Learning Disabilities and Autism Senior Programme Manager, Helen Smith, Education Quality Review Lead 

• Clinical Lead for Talking Therapies in the Midlands, Dr Sarah Watts, Specialty Expert 
• Senior Transformation Programme Manager and NHS Talking Therapies Lead, Birmingham and Solihull Mental Health Provider Collaborative, Katie Holmes, Quality Representative
• Head of Quality, Birmingham and Solihull Mental Health Provider Collaborative, Emma Watts, Quality Representative
• Director of Quality and Safety, Birmingham and Solihull Mental Health Provider Collaborative, Sarah Bloomfield, Quality Representative
• Quality Manager, Raj Sunner, Education Quality Representative

Review findings

Client suitability

PWP and high intensity trainees from multiple providers reported that ineffective triage resulted in them being asked to work with clients whose difficulties were too complex and beyond the curricula. Lack of appropriate clients caused several trainees to fall behind on their expected clinical hours shortly after starting.

Supervisors acknowledged the ongoing challenge of finding suitable cases for trainees and noted the overall complexity of work across the consortium, influenced by the urban location and diverse demographics.

Providers were aware of the difficulty in sourcing sufficient suitable clients. Our Roots proactively assembled a pool of appropriate cases before trainees began. Providers indicated that if client suitability remained an issue for specific trainees, they collaborated closely with LWC to source potential clients from across the consortium. However, this was often challenging when searching for specific presentations.

The LWC central team recognised that client suitability was an ongoing challenge. They felt that potential learning opportunities were being missed and emphasised the need for further efforts to optimise and direct suitable clients to trainees in a timely manner.

Service provision and caseload

Trainees from various providers expressed concerns about being used primarily for service provision, often feeling overwhelmed by the volume of patients and caseload. They reported that providers were not adequately prepared to accommodate trainees, nor did they adjust expectations and support accordingly.

Supervision

NHS England heard of instances of relatively new and inexperienced trainees assessing and managing complex cases and being required to handle high risk patients with minimal to no supervision and support. Trainees need immediate access to support/mentoring/supervision (as well as their weekly supervision offer) – if a risk or a complex situation presents, they will not know what to do in the moment and will need to ask a qualified or senior colleague.

Trainees from multiple providers reported being without a supervisor for several weeks. When supervisors were eventually assigned, they were sometimes not suitably qualified for supervision duties.

External supervision arrangements were made for those unable to secure a supervisor within their provider. Trainees noted that external supervisors and providers had on occasions different perspectives about ways of working and suitability of clients. In addition, it was difficult to contact the external supervisor at times.

Trainees suggested that better communication between providers and external supervisors could improve the overall training experience and prevent misalignment between supervisors’ recommendations and providers’ policies.

The LWC central team is reviewing supervision structures and preceptorships to integrate them into the consortium, supporting trainees and newly qualified staff.

Placements and learning opportunities

There was a disconnect between the opinion of trainees and supervisors on the quality of the training environment. Supervisors from local providers advised that they were responsive to the needs of individual learners and worked closely with HEIs to enhance the trainee experience; adapting as necessary to ensure trainees could progress through the course. On the other hand, trainees considered placements to be disorganised and unstructured, with trainees nearing completion without shadowing opportunities. PWP trainees were often required to organise their own training and shadowing without support or guidance from providers.

Induction

Inductions were deemed disorganised and ineffective by trainees, with providers ill-equipped to support and train them. Trainees reported that management was often unavailable at the start of their placements, leaving them uncertain about their responsibilities.

There was inconsistency in the delivery of mandatory safeguarding and risk management training across consortium providers, leading to trainees feeling unprepared and unclear on essential policies and procedures.

Trainees also reported a lack of knowledge and understanding of safety measures at their providers and were unsure about the policies and mechanisms for raising alarms. Onboarding was slow, with minimal communication, requiring trainees to chase basic information before starting.

The LWC central team is working to standardise the induction experience across providers. They have a centralised induction for each staff member, with local teams overseeing provider-specific inductions that must comply with a checklist provided by LWC. Additionally, online resources, including how-to guides and videos, were made available based on trainee feedback.

Supportive environment

Trainees reported that some providers did not understand or support their needs when concerns were escalated. Consequently, trainees sought support from their universities, which were helpful in addressing and resolving issues. The St Martins management team were described as supportive and accommodating.

The LWC central team and supervisors noted that there are trainee champions for PWP and high-intensity trainees. Workshops are offered to high-intensity trainees via Our Roots, covering various topics such as essay writing, shadowing, and co-therapy. The level of awareness and utilisation of this resource was unclear from our discussions with trainees.

Escalating concerns

Trainees reported difficulties in raising concerns with providers, feeling they were passed from person to person without ownership, which they found unprofessional and unhelpful. Higher Education Institutes were more responsive and supportive, and trainees valued their assistance. However, trainees sometimes felt caught between the provider and HEI when issues were being addressed. Some supervisors were reported to be unsupportive, discouraging trainees from raising concerns with HEIs and instead telling them to “get on with it.”

Supervisors noted that they often learned about issues through the HEI and requested that trainees raise concerns before reaching excessive levels of discomfort.

The LWC central team confirmed that multiple avenues are available for trainees to raise concerns, including forums, HR, surveys, trainee champions, and consortium members. However, LWC reported that there seemed to be anxiety among trainees about sharing feedback on providers.

Clinical assessment scores

It was reported that clinical assessment scores (minimum data set questionnaires) had been changed and overwritten downstream to facilitate entry into a specific pathway. This risks patients receiving inappropriate care to safely meet their mental health need according to the evidence base and is in contradiction to the Talking Therapies Manual and National Institute for Health and Care Excellence (NICE) Guidance. There is a need to investigate further whether this is happening more widely.

Governance

The LWC central team reported that an annual audit of all providers was conducted to monitor the clinical learning environment, using an internal framework to ensure minimum standards and expectations were met. They were aware of trainee issues with supervision and client suitability. In addition to the audit programme, regular meetings were held with providers to understand their experiences and challenges throughout the year.

The LWC central team acknowledged the challenge of ensuring consistent experiences for all trainees across the consortium in terms of supervision, induction, and workload, due to differences among providers and the level of independence within the consortium. However, they believed their framework and structures enabled them to maintain a suitable training environment with a strong focus on quality, workforce, and supervision, as well as a clear process for the trainees to escalate to the consortium when necessary. Review findings indicate that the framework and structures in place do not appear to be working and further work was required.

Areas that are working well

Areas for improvement

Immediate mandatory requirements

Mandatory requirements

Report approval

Report completed by: Raj Sunner, Quality Manager
Review lead: Helen Smith, Mental Health, Learning Disabilities and Autism Senior Programme Manager
Date approved by review lead: 11 December 2024

NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean, Midlands
Date authorised: 24 January 2025

Final report submitted to organisation: 11 April 2025