Executive summary
The panel thanked the Trust for participating in this Senior Leader Conversation (SLC), which was convened to review progress following the results of the GMC National Training Survey 2023.
The panel met with the Chief Executive, Director of Medical Education and senior educational and clinical leads and managers. There was a very comprehensive group representing the trust. The panel recognised the significant amount of work in Medicine, Obstetrics and Gynaecology, and Haematology has been undertaken to address the feedback from the 2023 survey.
The panel felt that the discussion from the trust representatives demonstrated commitment, organisation, and pride in their specialties.
Review overview
Background to the review
This Education Quality Senior Leadership Conversation was triggered by responses received via the 2023 GMC National Training Survey in Medicine, Obstetrics and Gynaecology (including GP programme) and Haematology specialties as well as open actions relating to clinical supervision, adequate experience, and workload.
Who we met with
Executive Team
- Chief Executive
- Medical Director
Medical Education Team
- Director of Medical Education
- Deputy Director of Medical Education
- F2 Programme Director Tunbridge Wells Hospital
- Head of Medical Education
Medicine
- Chief of Service Medicines and Emergency Care
- Deputy Chief of Service Medicines and Emergency Care
- Clinical Director for Medical Specialties
- Clinical Director for Acute Medical & Geriatric Medicine
- Medicine MGH College Tutor & D&E Lead
- Medicine TWH and MGH College Tutors
- D&E Educational Lead
- Clinical Lead for Frailty
Haematology
- Clinical Director for Clinical Haematology
- Haematology College Tutor
Obstetrics and gynaecology
- Interim Chief of Service Women’s, Children’s & Sexual Health
- Clinical Director for Women’s Services
- O&G College Tutor
- Deputy O&G College Tutor
- Divisional Director of Operations for Women’s, Children’s and Sexual Health
- Women’s Children’s General Manager
Review panel
Education Quality Review Lead
- Chris Carey, Associate Dean
Specialty Experts
- Nik Patel, Head of School of Medicine
- Burhan Khan, IMT Training Programme Director
- Mike Wood, Deputy Head of School of Medicine
- Catherine Wykes, Obstetrics & Gynaecology Training Programme Director
- Shireen Kassam, Haematology Training Programme Director
- David Harris, GP Training Programme Director
Lay Representative
- Martin Brand
NHS England Project Officer/Scribe
- Alex Bamford-Blake
Review findings
Medicine
When asked about the GMC NTS 2023 results concerning rota gaps, the panel heard that the Medicine department has established a network of managers that communicate with junior line managers and rota coordinators via WhatsApp groups to fill unforeseen rota gaps with volunteers. To fill foreseen rota gaps, the network seeks to find cover from the locally employed doctors (fellows), locum or bank staff to cover. The panel heard from Deputy Chief of Service for Medicines & Emergency Care that the Trust recruits through the Trust’s cohort of contract doctors that contractually receive a 20% pay increase if they are added to the medical day rota. It was reported that this has both reduced spending and increased quality of care.
In response to concerns of workload intensity, the panel heard that conversation between Doctors in Training and the department is ongoing. It was reported that specific feedback was from a junior doctor working party that was established during the COVID-19 pandemic to look at solving the issue of workload. Feedback from this conversation established the current rota, which has two phases, on-call and ward levels, and an increase from 22 lines at SHO level to 26 lines since August 2023. It was recognised that workload remains high in some areas although there are efforts being made to mitigate this.
When asked about the hospital’s ‘Hospital at Night’ plan, the panel heard that though there is currently no dedicated hospital at night team, the hospital is aligned with RCP advice and there is overnight ward cover and a third person on nights. It was reported that the department uses business intelligence to monitor peaks; when there is an increase in activity, the department assess the need for additional junior doctors. See Recommendations.
When asked about the Trust’s use of Electronic Patients Record (EPR) systems, it was reported that the Trust used multiple systems, some unique to individual departments, and that the Trust see this as a “weak point.” The panel heard that two years ago this lack of unified system was the single highest complaint at LFGs, but it has fallen significantly in the years since. It was reported that chief medical information officers (CMIOs) are collaborating with clinicians to improve these systems and that the Trust is working towards a unified EPR system.
When asked about educational supervision, the panel heard that all Educational Supervisors (ES) have 0.25 PA job planned for each trainee. Junior Clinical Fellows who do not have formal ES are encouraged to take part in Trust appraisals. The panel heard that the Trust has a job plan policy which sets out how many PAs are sent out to roles and how much time is to be allocated. The panel heard that all Junior Clinical Fellows have a have six-week induction with a lead shadowing and observing their ward rounds before starting independent practice. There are two allocated clinic days per month, an individual self-development plan, and core teaching is rostered. The panel heard that this applied to Internal Medicine Trainees (IMTs) as well, who have timetabled clinic access. Feedback has been that IMTs would like to know in advance which clinics they have been assigned. Junior trainees have allocated support time with registrars and job plans means that there is consultant presence on each ward every day. It was also reported that the Trust intend to reduce the size of clinics for doctors in training to improve the educational experience.
The panel heard that recruitment for substantive consultants to contribute to both service and educational activities is ongoing. The workload of current renal consultants means there is limited senior support. However, Postgraduate Doctors in Training are encouraged to request consultant support when they need it. The panel felt that it would be useful for the organisation to have a clear stated plan with regards to staffing levels and roles and responsibilities within medical specialties.
With regards to geriatrics and frailty challenges, the panel heard that fixed term consultants have been appointed whilst recruitment for substantive consultants continues. Middle grades are well staffed with two Higher Specialty Trainees, a specialty doctor and two Postgraduate Doctors in Training on the frailty ward. With recruitment, supervision will improve. See mandatory requirement reference MR-01.
The panel heard that all gastrointestinal surgery service has moved to Tunbridge site rather than being split with Maidstone. There is currently only remote supervision for gastroenterology registrars on the Maidstone site during the day, but this is being reviewed. See mandatory requirement reference MR-01.
Obstetrics and Gynaecology
When asked about the heavy workload within the department, the panel heard that a clear escalation plan for both elective and emergency work is included in the induction pack and that Postgraduate Doctors in Training are encouraged to escalate without reservation. The panel heard that during the daytime the elective caesarean lists are paused to accommodate emergencies but to reduce delays due to access to the second theatre out of hours, the Trust is looking at a business case to expand theatre and medical staffing. See mandatory requirement reference MR-02.
It was reported that there is consultant presence from 8.30am to 9.00pm, 7 days a week, an SHO is on the on-call rota, and consultants are responsible for the antenatal unit and emergency gynae cover. The department is trying to provide 8.30am – 1.00pm separate emergency gynaecological consultant cover, but this is currently not always possible. Increasing consultant numbers to separately cover obstetric and gynaecology emergency services, interviews for which start in July 2024, and increasing emergency cover from 8.30am – 5.00pm are parts of the department’s improvement plan.
The panel heard that to accommodate increased deliveries and caesarean section rates, there is senior presence on the delivery suite to manage patient deliveries as well as two junior medical staff (which includes F2, ST1-2, and Junior Clinical Fellow) at night to deal with activity. To expand maternity triage cover, there is now a member of the junior medical staff (as previously described) assigned to obstetrics, gynaecology, and the early pregnancy assessment unit; a fourth, to cover the ward on weekdays, is being considered.
When asked about the perception current Postgraduate Doctors in Training would have of the site, the panel heard that the recent CQC visit had raised concerns over safety and governance. This, along with the feedback from 2023 GMC NTS survey, prompted a series of meetings held since December 2023 to implement change. It was reported that the department has been responsive and continued to seek feedback from Postgraduate Doctors in Training via group sessions. Some of the issues raised were around expectations of educational supervision and teamwork. It was reported that improvements are ongoing, but that overall feedback from Postgraduate Doctors in Training has been positive. The panel heard that one criticism in the CQC’s feedback of the department was the lack of systematic learning regarding serious incidents. The panel heard that the department regularly assesses and discusses risk incidents in governance meetings, do drills accordingly, and communicate ‘lessons learnt’ to improve teaching and care.
Obstetrics and Gynaecology – GP specific
When asked about the rota, the panel heard that since 2023 a senior member of the team works with a rota coordinator. This has arisen due to feedback from O&G GP Doctors in Training wanting more clinic exposure. The department now keeps a log of Postgraduate Doctors in Training clinic and workshop attendance, and they are released from other clinical work to attend. The panel heard that teaching has expanded in response to GMC survey feedback and that a year-long teaching programme includes workshops and team sessions, including a separate GP teaching programme. From April 2024, the second Thursday and fourth Friday of every month are dedicated to GP training and Doctors in Training are released from clinical duties to attend. The panel heard that since March 2024, if the consultant leading the teaching session is absent, it is covered by a senior registrar or SAS doctor (specialist, associate specialist and specialty doctors) rather than cancelled and that this has been positively received by Doctors in Training.
Haematology
When asked about the training posts in Haematology, the panel heard that the department had faced challenges in recruiting for placements because of the Maidstone site location and previous split of training over the Maidstone and Tunbridge sites. It was reported that training is now solely located at the Maidstone site and that, from September 2024, there will be three training posts.
The panel heard that trainee exception reporting continues to demonstrate heavy workload, but that exception reporting numbers are lower than previous years. The panel heard that it had been a challenge to balance workload and rota with staff availability, but actions had been taken to address this. It was reported that Postgraduate Doctors in Training, no longer split between the two sites, have job plans that cover both ward and clinics. A day nurse-led clinic focussed on acute issues is based on the Tunbridge Wells site, but not every day, and there are no inpatients. Laboratory training with an on-call consultant continues to be a work in progress, but it is part of induction for all Postgraduate Doctors in Training, they do have it included in their job plan, and are able to report (overseen by two laboratory leads). See mandatory requirement MR-03.
The panel heard that to address feedback around local teaching, the department has implemented weekly, consultant led teaching sessions, morphology teaching and a journal club for registrars and SHOs.
The panel heard that there are currently not enough registrars to cover a whole week of on-call rota overnight shifts, but feedback has been satisfactory so far. The panel heard that there are now separate quarterly Local Faculty Group meetings for haematology/oncology Postgraduate Doctors in Training where they can voice what they feel the department could do better and address concerns. However, the first meeting in February was not attended by haematology. This will be addressing going forwards. These meetings will also include some educational supervisors and internal medicine trainees. The lead consultant for education meets monthly with Doctors in Training and educational supervisors to address issues in real time and ensure training needs are being met.
When asked about previous feedback around teamwork, the panel heard that criticism stemmed from lack of communication from and between consultants, changes to treatment plans outside of MDMs and a chemotherapy action sheet that fell on Doctors in Training to complete. The panel heard that there have been significant improvements in consultant communication with changes in staff and the old ‘action sheet’ no longer used with these tasks which are now solely completed by consultants.
When asked if they felt Doctors in Training would recommend the Haematology placement, the panel heard that a lot of changes have taken place year on year since the 2022 informal trainee survey and that improvement is ongoing.
Requirements
Mandatory requirements
| Requirement reference number | Review findings | Required action, timeline and evidence |
|---|---|---|
| MR-01 | There are plans for additional recruitment across the medical specialties, but this is still to take place in many areas. There were particular challenges with regards to the supervision of Gastroenterology trainees on the Maidstone site and also some comments with regard to consultant supervision arrangements in other medical specialties such as renal. | Please provide a workforce plan outlining current and future consultant and non-consultant numbers for medical specialties across the trust. This should include how on-site supervision arrangements will work across both sites for gastroenterology trainees. |
| MR-02 | The panel were told on occasions there were delays in maternity triage and a recommendation of the CQC was that the Trust should review maternity triage staffing. | The trust must implement regular consultant cover for gynaecological emergencies in line with specialty standards and CQC requirements. We will be happy to accept the findings of the review prompted by the CQC report. |
| MR-03 | The review panel were informed that although there were plans to introduce training in laboratory work for the Haematology trainees, there wasn’t a consistent process in place to provide this. | The haematology department should implement plans to ensure that regular laboratory work is supported for doctors in training in line with curricular requirements. Please provide a timetable for laboratory training. |
Recommendations
Recommendations are not mandatory but intended to be helpful, and they would not be expected to be included within any requirements for the provider in terms of action plans or timeframe. It may however be useful to raise them at any future reviews or conversations with the provider in terms of evaluating whether they have resulted in any beneficial outcome.
| Related education quality framework domain(s) and standard(s) | Recommendation |
|---|---|
| 1.5, 1.6 | The trust should consider the provision of a Hospital at Night service to support junior medical staff. |
Good practice
Good practice is used as a phrase to incorporate educational or patient care initiatives that, in the view of the Quality Review Team, deliver quality above and beyond the standards set out in the Quality Framework. Examples of good practice may be worthy of wider dissemination.
| Learning environment/professional group/department/team | Good practice | Related education quality framework domain(s) and standard(s) |
|---|---|---|
| Trust wide | There was an excellent turnout of education leads from each of the departments. Trainers understood their roles and were actively engaged with quality processes | 1.1 |
| Trust Wide | There was a high level of positive engagement from senior managers and trust leaders in the visit process reflecting a high level of engagement with matters relating to education and training in the trust | 1.1, 2.1, 2.4 |
| Trust Wide | Education leads from each of the departments involved had taken an active approach to following up challenges identified in last year’s GMC National Trainee Survey | 1.1, 2.1 |
Report approval
Report completed by: Alex Bamford-Blake, Education Quality Support Officer
Review lead: Chris Carey, Associate Dean for Kent, Surrey and Sussex
Date approved by review lead: 31 July 2024
NHS England authorised signature: Paul Sadler, Regional Postgraduate Dean for South East
Date authorised: 22 August 2024
Final report submitted to organisation: 30 August 2024