Review overview

Background to the review

We had originally planned to carry out this visit in 2023, but after new announcements about industrial action the review date coincided with a junior doctor strike, and we cancelled and later rescheduled to this date in 2024. Given the nature of the trust’s estate, spread out over a large geographic region, we decided to do a virtual visit.

Our original rationale for the visit in 2023 was part of a wider review into all of region’s mental health trusts and was not triggered by significant concerns held by the quality team. Moreover, the general psychiatry programme receives good feedback and various survey results from doctors in GP training at the trust is generally positive. There were negative outliers in some indicators for smaller specialisms that merited further investigation, which are the clinical areas we focused on for this visit: learning disabilities, old age psychiatry and forensic psychiatry.

With the postponement of this review, we had a new release of GMC National Training Survey data to analyse, which showed improvements in feedback for learning disabilities and for old age psychiatry. Forensics had outliers in the newer data.

Who we met with

Doctors in psychiatry training: 16 x doctors in postgraduate training in sub-specialty psychiatry training posts in either learning disabilities, old age psychiatry or forensic psychiatry, and at middle and higher grades ranging from CT1 to ST7.

Psychiatry educators: 16 x consultant psychiatrists with educational or clinical supervisory roles in either learning disabilities, old age psychiatry or forensic psychiatry.

Evidence utilised

• National Education and Training Survey (NETS) results
• General Medical Council (GMC) National Training Survey (NTS) results
• GMC NTS free text comments, trainer survey and burnout data
• Self-assessment return questionnaire
• Soft intelligence from the School of Psychiatry

Review panel

• Quality Review Lead: Paul Baker, Deputy Dean for Foundation
• Specialty Expert: Clare Inkster, Associate Dean for School of Psychiatry
• Trust Liaison: Rory McGill, Associate Dean for the trust
• Quality Representative: Zander Zambas, Quality Support Manager
• Quality Supporting Role: Leanne Moore, Quality Coordinator
• Quality Supporting Role: Shelley Cunliffe, Quality Coordinator 

Executive summary

We visited Mersey Care NHS Foundation Trust on 14 June 2024 for a Learner/Educator Review. Our panel found doctors in a range of psychiatry training posts at Mersey Care to be well supported, safely and effectively supervised and given plenty of learning opportunities with good access to formal teaching and frequent informal feedback from consultants.

The doctors in training and the educators we spoke to described a very good medical education team and a very visible, approachable and responsive Director of Medical Education. Good practice was led from the centre, and we had an insight into areas of the service that had a supportive and enabling working culture which facilitated safe patient care.

We did pick up on some specific concerns within each group that we spoke to, and some that we found throughout the distinct cohorts. For example:

• though the trust corporate induction was well regarded, there was little evidence of structured or planned departmental inductions to prepare doctors for a specific role
• abuse from patients to staff was not always prevented well, nor consistently followed up robustly if it occurred
• working relationships between grades, (sub-)specialties and professions was mostly good, but had broken down between certain groups in some contexts.

We will return to the trust for an in-person Senior Leadership Engagement review on 16 August 2024, where we will discuss the findings of the report and agree on the trust’s steps to resolve the requirements and recommendations of the report.

Review findings

Psychiatry of learning disabilities

We spoke to a cohort of four doctors in learning disability posts and asked a wide variety of questions about their experience of training. We were pleased to hear that the overall experience of the doctors was positive, and we heard that their educational requirements and expectations were largely met or exceeded.

The onboarding induction experience was variable. While it was clear that the trust has invested in its widely praised corporate induction, and schedules were received on time ahead of starting the rotation, there were gaps which left some new starters feeling unprepared. Some doctors had prior experience at the trust and so were not included in the induction, but also found assumptions were made about their access to systems. Two of the four doctors were not set up on the ePMA (electronic prescribing and medicines administration) system and one resorted to using pen and paper prescriptions until it was sorted. However, there were no issues with schedules and paperwork, which was all received in a timely manner.

The doctors we spoke to were happy to relate to us that they really enjoyed their work and the post they were in. We were told that there were lots of opportunities for learning across the two sites, including opportunities to do independent clinics and clinics with consultants. Although the on call shifts were busy, this did not detract from the overall experience. There was an appropriate level of responsibility for each grade and where one doctor described occasional times of feeling overwhelmed with the work/responsibility there was always help available.

Across the board, doctors in this session worked closely with one or more consultants and described it as easy to get assessments and competencies signed off. Not only were trainers highly accessible, some were described as proactive, and offered ideas on how to approach the curriculum and complete competencies. Middle and higher grade doctors were very positive about feedback they got from their supervisors, describing “everyday mini-supervision” giving a “constant stream of feedback”.

Handovers were labelled “procedural”, and there were teething issues with access to a handover document on the G: drive resulting in another interim pen-and-paper process. However, on a positive note, the handover and rest facilities at Hollins Park were appreciated; one doctor said the facilities are “very good – the best I have had in four years of being a doctor”.

Clinical governance and incident reporting was understood well. Several doctors had raised incidents and were able to explain the follow up process of “huddle” meetings with managers and consultants. One doctor who had used the system said it was “thorough, but cumbersome and time-consuming”, while remarking that the follow up was also thorough and “impressive”. All agreed that this was a safe process for staff and for patients.

Everyone present was clear on who their clinical supervisor was, and who their educational supervisor was. One, who had been paired with the same educational supervisor throughout core training described themselves as lucky. All supervisors appeared to be approachable, accessible and supportive. We asked about other key people supporting educational roles, such as the Guardian of Safe Working Hours and the Freedom to Speak Up Guardian. The cohort was unclear on the difference between these two guardians, which we explained to them.

Formal teaching was available to all the doctors in training we spoke to. There were local and regional sessions, with a variety of frequencies depending on staff grade. Teaching time was protected time on the rota, though we heard it was difficult to get the time off to attend training when on call. Importantly, we learned that there were complaints about accessing the formal teaching in the previous year and that a responsive education team had made changes and improved this issue for the new rotation.

The working relationship within psychiatry was seen as a real positive by the doctors in training. The group talked about a flattened hierarchy, the prominence of nurses in leading care – particularly in care of patients with learning disabilities, and cohesive multidisciplinary team working. The only negative described was about the management of patients’ physical health; as the nurses in this setting are often less competent in managing physically unwell patients (than nurses in an acute setting, for example), this always falls to the doctors in training as the most senior medic. It was often difficult to manage the physical health elements of the job alone, and doctors particularly felt worried that they were not always able to leave patients in safe hands.

An aspect of working in psychiatry of learning disabilities that was viewed by the doctors as somewhat inevitable was inappropriate behaviour from patients, including comments and abuse which were sexual in nature or using racist language. As a panel we were then particularly interested in how the trust supported doctors and other members of staff and what the trust protocols and culture could do to prevent and/or mitigate the potential damage of this kind of abuse. In sharing specific cases of this kind of behaviour, we heard that members of staff were supported, but the situation was “not dealt with as well as elsewhere”. Staff-on-staff abuse was not as common for this group, though instances of high expectations from nursing staff and sometimes heightened stress levels have led to “being spoken to in an unprofessional way”. It was said that patients were consistently treated well, and with dignity and respect.

In summation at the end of this session, we asked the doctors in training whether they would recommend this training post to a peer. Taken as a whole, they all agreed that they would recommend this post. One did suggest that the learning disability post did not offer as much training experience as, for example, a CAMHS (child and adolescent mental health service) post but had no issue with the trust and the rotation. Another specifically said that they were now seriously considering psychiatry of learning disabilities as a career – a ringing endorsement.

Old age psychiatry

The trust’s “very thorough” two-week induction received praise from this group as well. The local introduction to the department, however, was simply a one-to-one chat with a consultant. This did help new starters to feel supported and welcomed to the placement, but not necessarily prepared to start work. We also specifically heard that in some cases the rota was not sent out until three or four weeks before the placement started.

This post provided good opportunities for independence for higher grades, while still offering support where necessary. We did find evidence of higher grades feeling deskilled in some clinical areas (e.g. personality disorder), and one specific section 12 approved doctor was cited as refusing to do workplace-based assessments, and “taking over” assessments without incorporating training into the process thereby preventing adequate experience of Mental Health Act assessments.

On call shifts were described as occasionally intense, and the calls as quite frequent during these. We heard that it was impossible to build rest into the on call shifts, there was “no scope for having a break”. The doctors reported that concerns had been raised with the trust about the lack of a rest policy and they felt as if the concerns had been “pushed back”. We took some comfort from the assertion that no patient or staff safety incidents were known to have taken place due to this lack of rest.

When we asked about supervision, we were unanimously told that these doctors had educational and clinical supervisors, they knew who they were, most of the time they had their one hour a week of supervision and that sometimes – though not consistently – this was recorded in their portfolio.

Regional teaching in Manchester was highly valued by the core doctors. It is quite a distance to travel, but we learned that travel was reimbursed, the teaching was of a high quality, and it provided an opportunity for team building with other doctors in training. For higher specialty training, the teaching was arranged by other doctors in higher specialty training and it was frequently hard to get to it as there was often not the requisite six weeks’ notice.

On the subject of raising concerns, at least one doctor had used the incident reporting system and confirmed that there was follow up including feedback.

We were curious to learn about discrimination in the workplace, and although the doctors we spoke to experienced “significant racism” and “a lot of verbal abuse” from patients, it was not usually recognised as a problem and the vast majority of this behaviour was not brought to the supervisor’s attention.

In contrast, we heard that staff working relationships were positive on the whole. The clinic setting was “lovely” in terms of culture and inter-staff relationships were described as supportive. The only exception we heard about was in the Heys Court in-patient setting, described below.

We asked specifically about physician associates and working with and alongside them. One doctor did have experience of working with a physician associate, and valued them as a colleague while observing that she posed no threat to training opportunities for doctors.

The conversation briefly covered several topics, in which we found no issues and doctors at all grades to be satisfied by the provision. These included access to study leave, support to carry out audit, educational resources, and opportunities for leadership roles.

All present endorsed recommending the placement as a place to further training. In explanation, the supportive individuals and the supportive culture in the team was commended, with one doctor saying they were fortunate to have the “best consultant” possible.

Heys Court

One important aspect of the post, which the doctors told us was not made clear to them until quite late, was the inclusion of covering the long-stay old age unit at Heys Court. It was reported that this felt like a distinct, separate part of the job. Its inclusion came as a surprise, and it was “tagged on with little explanation of scope” as an addition to what felt already like a full-time job.

Moreover, we heard that care at Heys Court “has no educational value, it’s just service provision”. It was described as providing a GP service. We understand that a GP attends once a week. Between these visits, we heard of nurses calling middle-grade doctors to carry out ear syringing and routine bloods at 4am, along with the “threat of Datixing” (i.e. raise a clinical incident) if it’s not carried out in a timely manner.

Delivering the service was said to be stressful as the patients were not known to the doctors in training and the nurses on site expect a very responsive presence from doctors without knowledge of the rest of the doctors’ caseload. While we heard empathy for the stress the nurses were also under due to the workload, this was perceived to result in “an infantilising tone” and incivility between the professions in this setting.

A further challenge was with facilities; it was reported that there were not enough computers at the Heys Court site, some computers did not work, and the trust did not issue laptops to all the core doctors in training (but did issue laptops to higher specialty trainees). The impact of the lack of laptops was spelled out for us: one doctor needed to go to the office every morning to get patient addresses and notes before doing home visits, taking up to an additional hour every morning compared to the possibility of going straight to the home visits. There appeared to be challenges with a complex IT ecosystem with legacy “mid-Mersey” systems needing different accounts and login details (an issue not just limited to Heys Court). The rest rooms and break out areas were also described as “mouldy and smelly”.

Finally, it was suggested that the historical concerns about Heys Court had been raised and known about for ten years, but the problems have persisted.

Forensic psychiatry

Induction at Ashworth was a local induction which did help new doctors to feel prepared. The on call induction was provided by other doctors in training, and it was helpful. Everybody received their IT system logins in a timely way. Overall, a good start to the forensic posts. We did hear about more difficulties navigating the IT ecosystem, such as a doctor who claimed to have access to only one of three necessary systems for on call shifts because they were “from the Manchester side”.

We were pleased to again hear that all of the doctors we spoke to were regularly receiving their scheduled hour per week of supervision. We also heard that supervisors were highly accessible and hands-on. We did deduce that learning does depend on which consultant one is paired with “more in this job than elsewhere”, and that doctors in training who were more proactive got more opportunities, but also heard that the consultant body was broadly speaking enthusiastic about training and engaged with the needs of the doctors in training. One doctor shared that they had been assigned no educational supervisor for this year, but were lucky that their educational supervisor from the previous year had agreed to roll over the arrangement on an informal basis.

The balance of responsibilities was judged to be right, with no demands above and outside the doctors’ competence and not much “educationally unproductive” time either. Everyone was happy with the opportunities and felt that they were getting everything they needed for their portfolios. This contrasted somewhat with the report that the “bulk of work” for core doctors was general medical physical health, citing examples such as attending a sprained leg after playing football. It was estimated that “60-70%” of the workload was this type of physical health, which the doctor expressed was not their expected remit.

In this session we learned about the new incident reporting/management system, Radar. The cohort of doctors knew how to raise concerns, from clinical incidents to unsafe practice, using Radar, their supervisors, or the Freedom to Speak Up Guardian which they had learned about at their induction. They were also aware of exception reporting additional hours, but had not had reason to use this.

Regional teaching for these doctors is on a range of topics and the quality was described as good. We heard that doctors receive protected time to attend these. Study leave was easy to obtain, although we were told of a doctor missing out on an expenses payment due to an easily made administrative error on the expenses system. The suggestion was made that travel expenses that are not approved come with better communication to allow prompt follow up if necessary.

Audits were supported, and doctors found time to achieve these. The educational resources were praised, including the three libraries across the trust and the system for sending books between them upon request. A responsive knowledge services team was appreciated, including the offer of doing a literature search, and online access was useful.

These doctors working on the forensic units told us that abuse from patients was commonplace in this setting, including verbal abuse and discrimination based on protected characteristics. However, they said “staff are very supportive”, consultants/supervisors will support and check in and that counselling is available. We were told of a proportionate use of police reports for patient abuse. We discussed the choice that doctors may make following abuse of whether to continue to provide care to an abusive patient, and we were told about some specific incidents and how they were followed up.

Workplace relations involved some tension. We heard again of nurses under pressure from patients being short and threatening with doctors over the phone. We were told of a specific instance of a colleague seeming to deliberately frustrate and obstruct the clinical work of a doctor. However, within the psychiatric team, there was a clear benefit to having lots of long-standing members of the team on the Ashworth site, with a good mentality and a good culture. We heard positive feedback about working alongside a physician associate again.

The panel shared thoughts about the Panorama undercover investigation into Greater Manchester Mental Health NHS Foundation Trust’s Edenfield Centre which culminated in the September 2022 broadcast Undercover Hospital: Patients at Risk. In particular we were curious to know of any learning that had taken place at Mersey Care following these revelations and whether any of the doctors in psychiatry training had observed or even suspected similar forms of health and care malpractice at this trust. It was interesting to hear that teams here have discussed the Panorama programme in training sessions, and learning linked to this investigation clearly had taken place. We were also assured to hear that none of the doctors present had any concerns about abuse of patients at either the Ashworth or Rowan View sites.

Every doctor in psychiatry training we spoke to from the forensic units told us they would recommend the post.

Educators in psychiatry of learning disabilities

The educators in psychiatry of learning disabilities shared that they had no concerns about the support they were receiving to do their work. They shared that they had “very good support systems”, from mechanisms to escalate concerns and a robust response from the wider team, to good peer support. They felt valued, the trust was seen to be flexible, there was protected supervision time in their job plan and no issues with study leave were reported, with many courses online and the leave easy to access. Some lamented the loss of an internal course for trainers on “supporting a challenging trainee”, and there seemed to be an appetite for bringing this back.

Their education role was linked to their appraisal, a “360° appraisal” which covers the seven domains of education standards and elicits feedback from the supervised doctors in training. Further sources of feedback from doctors in training were listed, including simple verbal feedback at the end of a placement and thank you cards and notes, and feedback collected by the deanery. We suggested that trainers give doctors an opportunity to feedback confidentially and/or anonymously and/or after their ARCP (Annual Review of Competency Progression).

After hearing the doctors in training talk about “thorough and impressive” patient safety, it was good to triangulate this with the perspective of their supervisors, who told us that the patient safety team had been “beefed up” and the new streamlined approach to escalating concerns has had benefits to patient safety and to the culture around speaking up. They agreed with our assessment that doctors in training had the confidence and knowledge of how and where to escalate, and confirmed that feedback is given to doctors at all levels. We learned more about the daily “huddle” and rapid reviews, and the team described a “really open, no-blame culture of learning around incidents”.

When we talked about incidents of particular concern – abuse from patients involving a racial or sexual element or concerning other protected characteristics – we heard from the educators about their approach to dealing with these experiences themselves and supporting doctors in training. This was clearly an ongoing topic of conversation between trainers and those they supervise, covering the risk of violent patients, lone working policies, police involvement, the impact of abuse, support from the trust medical education team and beyond and more. We were pleased to hear it clearly articulated that doctors in training were asked if they wanted to continue with the care of a patient who had been abusive.

Old age psychiatry educators

We began our conversation with the consultant body for Old Age Psychiatry on the encouraging note that they felt very supported by the medical education team, there was plenty of information coming from the centre and problems were quick to be resolved.

Supervisors had a specified two hours per week in their job plan for supervising each doctor. The variability in supervised doctors is quite wide. We heard of registrars who are very easy to work with, contrasted with some GP+ (or ITP: Integrated Training Programme) doctors with no experience in psychiatry, or indeed in the NHS, and need a lot of support, a few months of shadowing and sitting in clinics etc. The panel discussed the upcoming change to GP training and the widening of GP+ integrated training programme placements, and the potential impact that this may have on supervisory obligations.

The study leave policy was outlined, though we heard a case in which a consultant applied in plenty of time for study leave and confirmation of the leave come through after the date of the leave had passed.

Consultants with educational responsibilities confirmed that education formed part of their appraisal. Supervisors had access to a “train the trainer” course, as well as online mandatory training, which included EDI (equality, diversity and inclusion) training, we heard of a planned supervisors away day on 20 October 2024.

In addition to the basic mandatory EDI training, there were further resources. A recent session on neurodiversity and reasonable adjustments was relevant to the job, and we learned of another planned session on “cultural competence” coming up on the 22 November 2024.

As we discussed with the doctors in training, abusive incidents and inappropriate comments from patients do occur. We felt strongly assured that these incidents and comments were brought up and discussed in supervision sessions as a matter of course. In the context of some specific, shared examples of this kind of behaviour, we covered the trust’s “zero tolerance” policy for racism and the various channels for feeding back (including the Freedom to Speak Up Guardian).

We were keen to ask supervisors about Heys Court, which seemed to be a source of great frustration to the doctors in training we spoke to earlier. The supervisors informed us that doctors at Leigh Moss cover Heys Court, and that it is on the rota. They accepted that it is not necessarily clear from the induction or introductory communication with the new doctors on rotation, and that the breakdown in communication contributes to the feeling they had of being “blindsided”. They further agreed with the earlier cohort that the nurses’ standard of medical knowledge is very low, and therefore the threshold for calling for medical support was also very low. It remained unclear to us why doctors assessing the risk of the summons (for matters such as blood results) and refusing to travel and attend the site, led to abusive interactions with the nurses. It was clear, however, that some improvement was possible and necessary in these working relationships.

Forensic educators

We had no safety issues to feedback to the forensic consultant body and had overall positive feedback from the doctors in training. We heard this sentiment echoed from the supervisors’ point of view. They told us they work closely with and alongside the doctors in training and regularly check in and deliver informal teaching, do small teaching group sessions and generally receive positive feedback about the experiences of those in training posts. Anonymous feedback is sought from all departing doctors in training and the feedback seems to be of genuine value to the supervisors as well as the medical education team. Regular medical meetings and an approachable Medical Director also provided a route for doctors in training to raise or escalate concerns, another source of feedback for the team and trust.

The opinion of the consultants was that psychiatry is a good specialty for flexibility, and that the trust and team are able to support alternative work patterns, for example, and champion a positive work-life balance.

Educators themselves felt valued and there were peer support networks. Support was also available from the “very accessible” Director of Medical Education and also from relevant TPDs (Training Programme Directors). Supervision was in everyone’s job plan. Study leave was available and educators were supported to attend training and conferences. Appraisals included education and training responsibilities. In general, we built a picture of good governance in place to support the educators at each of the forensics sites of Ashworth, Rowan View and Rathbone.

Some supervisors were supervising up to 6 trainees, which was “manageable, but a bit high”, while recognising that this was caused by lots of vacancies and locum cover, and not a unique problem to Mersey Care.

We were concerned about the experience of abuse from patients which was shared in our session with the doctors in training, and we explored this further with the supervisors. It was confirmed that EDI (equality, diversity and inclusion) was part of the appraisal process and was included in mandatory training. We heard more detail on processes for handling sexual incidents, racism, and other forms of discrimination. We learned that the trust is developing a policy on sexual safety.

The GMC National Trainer Survey 2023 had a negative outlier from forensic educators for the Handover indicator, and we took the opportunity to ask if there were any known issues or concerns among the consultants about the effectiveness or safety of the handover process. Despite several different prompts, we were unable to identify any such concern among those present.

When queried about workplace relations, the educators at Ashworth shared much the same view as doctors in training there: that there were no issues to report, and doctors and nurses seem to get on well together at that site. We also corroborated the view that the two physician associates were valued, “a real asset”, and well supervised to do lots of routine health monitoring which frees the doctors in training up to do psychiatry. The only source of tension we could identify was with concerns raised by a foundation doctor at Rowan View.

We had heard from several groups of doctors in the morning that number and complexity of IT systems were an issue, and we put this to the supervisors. They identified the main frustrating factor which is a lack of access to Emis for physical health issues. Although they joined the chorus of doctors this morning saying access for all would be helpful, safer and more effective, they believed the financial cost to be the single barrier to resolving this issue.

Requirements

Mandatory requirements

Recommendations

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.

Report approval

Report Completed by: Zander Zambas, Quality Support Manager
Review Lead: Paul Baker
Date signed: 26 July 2024

NHS England Authorised Signature: Paul Baker
Date signed: 26 July 2024

Final report submitted to organisation: 30 July 2024

Publication reference: PRN01548