Executive summary

The ophthalmology department at University Hospitals Plymouth (UHP) has engaged in a wide range of education quality improvements during the triggered visit process.  They have navigated a move to a new eye unit, off-site and provided improved theatre access and a good working environment for postgraduate doctors in training (PGDiT). 

They have maintained the good communication between the department and the PGDiT.  Great support is noted from the college tutor and department manager.  Training needs are now clearly considered alongside service needs with bespoke solutions offered where necessary.  The teaching programme is well thought of. 

The department regularly monitor and audit data related to training.  This has led to an improved use of exception reporting to look for concerns with timetabling.   

The split site working when on-call has thrown up some challenges in access to ophthalmology medications on the main site out of hours and time pressures as PGDiT move between sites.  However, the PGDiT have felt able to raise these concerns and the department is enacting plans to ensure improvements.  

Staffing is an ongoing challenge for the department, who actively recruited within the last year, but again find themselves short of staff due to reasons beyond their control.  This will lead to service pressures, particularly in covering the urgent care clinics.  Again, the department have recognised this and are looking ahead to arrange cover for these clinics, including consultant cover, to minimise the impact on PGDiT.  They are reviewing processes on the main hospital site and making a case for altered telephone access for patients to manage the workload most appropriately.  They are also actively recruiting and the human resources department is supporting the recruitment process via new starter accommodation information packs. 

The panel heard of a continued commitment to improvement, support for doctors in training and a very positive working environment in the new eye unit. 

The panel have asked the Trust for reassurance regarding provision of ophthalmology emergency medications on the main hospital site for managing patients in the main ED.  The School of Ophthalmology will continue to monitor the ability of PGDiT to achieve their curriculum requirements, with support and data from the college tutor at UHP. 

Overall, the PGDiT reported that they would recommend UHP as a place to train in ophthalmology.  The panel have agreed to close this series of triggered visits.  This site and programme will return to routine quality monitoring. 

Review overview

Background to the review

The review is a follow-up from an original visit undertaken in January 2021 and follow-up visits of July and November 2021, April and November 2022 and July 2023. The initial concerns visit was triggered by an adverse quality panel outcome. The placement was graded as inadequate with particular concerns raised about the culture and behaviour of key individuals to trainees. Subsequent visits have highlighted issues around workload, service pressures and the impact of targets on training.  However, the department was found to be engaging and actively monitoring educational opportunities, with improvement actions underway. The subsequent visits also highlighted excellence in surgical training for senior postgraduate doctors in training, good support from the college tutor and department manager and a very positive change in culture.

Since the last triggered visit in July 2023 the ophthalmology department had moved to a bespoke new building off site from the main hospital.  The aim of this follow-up triggered visit was to ensure improvements were embedded and that the training environment remained of a high quality in the new site.  The visit took into consideration updated data from the ophthalmology department regarding attendance at training opportunities, (particularly cataract surgery), rostered development time for postgraduate doctors in training, and exception reporting data.  This data confirmed a high level of monitoring by the department, engagement with all recommendations from the previous visit and the majority of targets being met.

Who we met with

Learner

• Learner – ST Ophthalmology

Educators

• College Tutor – Ophthalmology

Education team

• Clinical Service Lead and Manager – Ophthalmology
• Deputy Chief Medical Officer  
• Head of People   
• Director of Medical Education
• Medical Education Manager   

Review panel

• Education Quality Review Lead – Helen Waters, Associate Dean for Quality (Peninsula)
• Specialty Expert – Tamsin Sleep – Head of School and Training Programme Director for Ophthalmology
• NHS England Lay Representative – Bill Wylie

Review findings

Domain 1: Learning Environment and Culture 

PGDiT (postgraduate doctors in training) present were very positive about the move to the new Royal Eye Infirmary (REI) building, separate from the main Derriford Hospital. They have been working from there for over 6 months.  They said that it was purpose built, has a good flow, well designed clinic rooms, three new large theatres that provide PGDiT with a lot more theatre exposure and that it is a good environment to work in.

PGDiT present also praised the college tutor as ‘fantastic’ and noted that he regularly touches base with the PGDiT and has stepped in to assist with urgent care clinics on occasions to protect training opportunities for the PGDiT. They also said that management and the PGDiT get on well and that consultants treat them well.  They reported polite and grateful communications from administrators in the department to PGDiT.

The panel heard that referrals to the ophthalmology department are mostly of a high quality and appropriate. The PGDiT praised the urgent care ophthalmology nurses as very good at knowing when to escalate.

One PGDiT had regular experience working in the theatres at New Medica and reported this as a good environment with appropriate cases that were within his competence and also appropriately challenging.

The PGDiT present said that although there were a couple of areas where systems could be improved that they would recommend this placement to their colleagues in training, as it is a good learning environment and they have enjoyed their time at UHP.

Domain 2: Educational Governance and Commitment to Quality 

The panel noted data from the department showing that exception reporting was being done and that the reports were being reviewed within the department.  The PGDiT also reported being aware of the exception reporting system and using that system.  As is the case within many departments and Trusts, the reports are more usually used for working over timetabled hours, but should also be used for missed educational opportunities. The panel have suggested that any email asking PGDiT to cover additional work at short notice could include a note reminding them to use the exception reporting system to flag any missed educational opportunity as this will help the department to rearrange those opportunities and monitor any gaps between staffing and service needs.

The panel noted audit data from the department and feedback from PGDiT confirming that specialty training doctors year 1 and 2 were no longer being asked to cover pre-operative assessment clinics, which is not considered appropriate training.

The panel noted how job plans and rosters had been altered to appropriately label the curriculum required development sessions for PGDiT as RSTA (research, study, teaching and audit) time to highlight the importance of these sessions and protect them from being sacrificed for short notice cover.

Domain 3: Developing and Supporting Learners 

PGDiT reported a good teaching programme.  They reported good access to specialty clinics and theatre lists.  They reported good consultant support.

PGDiT reported concerns regarding the current staffing shortages and how this may impact on their education opportunities.  They did not appear aware of the efforts the department is currently making to fill these posts and protect their educational opportunities (discussed under domain 6).  The panel have suggested some targeted communication with learners to allay concerns.

PGDiT reported some difficulties with the on-call system now that their work is split between the eye hospital (daytime hours) and the main Derriford hospital site (evenings and out of hours).  In the afternoons they can find themselves completing a session in the eye hospital (possibly another clinic or RTSA session),but feeling the need to step out of this to manage cases on the Derriford site, for example patients in the emergency department or wards who are too unwell to be moved to the eye unit for review.  On a busy day they may need to complete this work, return to the eye unit and then attend the main site again later that evening for more on-call work.  The panel appreciated the difficulty in managing care over the new split sites.  The panel noted that both the PGDiT and the department reported meetings to discuss these concerns and improvement ideas to try to mitigate concerns.  The initial step planned is to reduce afternoon commitments in order to reduce time pressures on the doctor on-call.  Wider solutions involve the recruitment of staff and some change in processes as discussed under domain 6.

The panel also heard that there is an issue with availability of medicines, eyedrops and other key drugs required for ophthalmology work in the main building.  This is of concern when a medication is needed urgently for patient care.  They reported an ophthalmology medication cupboard in the emergency department (ED), but that it was not restocked regularly. They reported an ophthalmology kit bag kept on the UHP site, but that this also would need regular restocking to remain of use.  The PGDiT had flagged this to their department.  Steps had been taken by the ophthalmology management team to confirm who was responsible for restocking of the ED ophthalmology medication cupboard.  This has been followed up more recently with joint department discussions, involvement of the ED matron and pharmacy and agreement reached that a named individual in ED will take responsibility for medication stocking.  The panel recommended that an audit was completed to reassure and support PGDiT and to ensure the new process was working and robust.  The panel flagged this concern to the Trust senior leadership team to ensure senior oversight of a potential safety issue that sits across 2 different departments, in terms of responsibility.

Action: Senior team to provide evidence to the quality team of a reliable stock of medications in ED for ophthalmology emergencies.

Domain 4: Developing and Supporting Supervisors 

Previously reported tensions between service targets and the consultants’ ability to support learner needs were not reported on this visit.  Good examples were shared of consultants being able to alter operative lists and allocations to ensure support for a PGDiT who needed additional supervision.

Domain 5: Delivering Curricula and Assessments   

PGDiT present said that urgent care clinics (UCC) are generally a very good learning opportunity, but that once a week was sufficient and would leave time for other specialty clinic and theatre opportunities.  It was generally agreed that PGDiT should not be pulled into additional urgent care clinics at the expense of their other learning opportunities.  The department report actively looking ahead at UCC cover over the next couple of months, in their period of staff shortages, and have found cover for the UCC clinics, including consultant cover, to avoid a negative impact on PGDiT.

One PGDiT present is doing an extra cataract list, while another is regularly attending a NewMedica cataract list with appropriate patients. 

Domain 6: Developing a Sustainable Workforce   

The department recognise that a PGDiT on-call may have to be on-site beyond 9pm if there is a challenging case.  They are clarifying the working time directive to ensure individual well-being and have a system whereby a PGDiT can contact them if next day’s activity needs to be cancelled to allow safe working.

The department recruited additional staff within the last year.  Both the PGDiT and the department representatives had reported a positive improvement in rostering and need for short-notice cover, particularly for urgent care clinics (UCC).  This was confirmed by department audit data. Unfortunately, they are again in a period of staffing difficulties due to a combination of sickness, annual leave, and colleagues who have relocated for lifestyle reasons. The department report a proactive look ahead at sessions to arrange cover, including consultant cover, for UCC to reduce the need to ask the PGDiT to cover at short notice.

The department are actively recruiting staff at the consultant and middle grade level.  They acknowledged that the Trust financial position has added a 1-2 week delay in the job advert process due to additional finance checks.  They are concerned that local accommodation difficulties create a barrier for potential applicants. The senior Trust team report that it is exploring affordable housing options for staff and has developed an accommodation information pack and landlord database to support easier recruitment.

The department is also looking at measures to streamline work to support a sustainable workforce.  They are working on a business case to run a patient advice line, allowing direct access for patients with ophthalmology concerns which could direct patients to the eye unit more efficiently, rather than to the emergency department out of hours.  They are also arranging training for the neurology ward and neurosurgery ward staff at the main UHP site to ensure they can complete visual field assessments using appropriate equipment.  This would lessen the need for ophthalmology on-call staff to move between sites and free up time.

The panel heard that there are parking issues whereby there is no allocated space for PGDiT which is adding up to an hour to their working day. Unlike other staff members who work permanently in one hospital, the PGDiT rotate to hospitals across the region and often rely on using their car.  The Trust is aware of this difficulty and looking at wider access and parking solutions.

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Helen Waters, Associate Dean for Quality 
Review lead: Helen Waters, Associate Dean for Quality 
Date approved by review lead: 18 June 2024

NHS England authorised signature: Dr Geoff Smith Regional Postgraduate Dean, SW 
Date authorised: 26 June 2024

Final report submitted to organisation: 1 October 2024

Publication reference: PRN01548