Executive summary

The review team would like to thank the hospice team for their flexibility in accommodating the review. The review was undertaken by NHS England Education Quality to ascertain progress with the actions required to address previously identified concerns around supervision. The review team met virtually with the hospice team to discuss this and brief feedback was provided at the end of the review.

The review team were encouraged to hear of the progress with consultant recruitment to the team at Woking Hospice, consolidation of the senior leadership team and their commitment to medical training.

However, the review team identified some areas where further assurance was required to ensure training would meet Education Quality Standards and issued four mandatory requirements relating to adequacy and consistency of clinical supervision arrangements and the procedure for doctors in training to access senior support out of hours. It was agreed that a decision could not be made to reintroduce training at the hospice until clinical and educational supervision arrangements were confirmed.

The review team would like to meet with the hospice team in April/May 2024 to review progress with the mandatory requirements which will further inform decision-making regarding reintroduction of Palliative Medicine training at Woking and Sam Beare Hospice.

Review overview

Background to the review

This Senior Leader Conversation was arranged to review progress following previously identified concerns around the adequacy of clinical and educational supervision, which led to the relocation of a Palliative Medicine specialty trainee in May 2021 and subsequent suspension of training at the Woking and Sam Beare Hospice. NHSE (NHS England) KSS Quality have required the hospice to provide regular updates on recruitment as confirmation of improved staffing levels within the unit and have outlined the requirements for the provision of clinical and educational supervision.

NHSE (NHS England) KSS Quality are keen to support the hospice with the reintroduction of Palliative Medicine specialty training which meets the Quality Standards. This Senior Leader Conversation provided an opportunity to understand progress with this and support decision-making around the reintroduction of training.  

Who we met with

• Chief Executive
• Director of Clinical Services
• Palliative Medicine Consultant

Review panel

• Education Quality Review Leads Dr Cathy Gleeson – Palliative Medicine TPD KSS and Dr Peter Anderson – Associate Dean
• External Specialty Expert – Dr Nick Gough – Palliative Medicine TPD London
• Specialty Expert – Professor Nik Patel – Head of School of Medicine
• Lay Representative – Jacqueline Codrington
• Scribe Sarah Stanbridge – Quality Project Officer
• Observer – Alex Bamford-Blake – Quality Project Officer 

Review findings

The review team heard about the recent changes in senior leadership including a new Director of Clinical Services starting in May 2023 and Chief Executive in June 2023. The Palliative Medicine Consultant has been employed at the hospice for seven years. The review team heard about the senior hospice teams’ collective experience in palliative medicine. The Chief Executive explained that despite the recent absence of the Medical Director/Lead Palliative Medicine Consultant, they feel the hospice is running well. The hospice team reported that the hospice supports 2,000 patients in the north-west Surrey area, 80% of which is care in the community services with a well-established community team including Clinical Nurse Specialists, hospice-at-home team, therapists, paramedics, and palliative medicine consultants available daily.

The review team heard that the hospice’s 20 bed inpatient unit, which provides specialist care for complex patients, had in the last six months experienced an increase in occupancy, averaging at 60-70%. The hospice team reported that they had prevented 58 hospital admissions in the last quarter. The hospice has two Advanced Nurse Practitioners (ANPs) that work closely with the medical team to support nurses on ward. The hospice is currently facing three vacancies across its clinical workforce (in nursing and therapy perspectives). The current medical team includes the:

• the Palliative Medicine Consultant who works eight sessions per week at Woking Hospice;
• two Advanced Nurse Practitioners previously mentioned;
• a locum consultant who works five sessions; they are employed on a rolling locum contract and planning to apply to be on the specialist register via the CESR route (Certificate of Eligibility for Specialist Registration)
• a “SHO” who has been at the hospice the last six months;
• one bank doctor at the end of GP training who has provided sessions for more than a year;
• the hospice recently interviewed for a locum consultant. The candidate, who has accepted the offer, is a senior consultant and experienced educational supervisor, and is due to start in March 2024 (on a one-year fixed term contract). They will attend six sessions per week.
• Medical Director role is currently vacant. – The senior consultant had been leading the medical team due to the absence of a Medical Director, whilst they are on long term leave, the medical team is working closely with the Director of Clinical Services and Dr Tsiompanou attends the Senior Leadership Team Meetings and Trustee meetings as the medical Representative.

The review team heard that the hospice hosts placements for an F1, F2, GPST 2 doctors from St Peter’s Hospital and that in the last year they have been offered a training doctor from abroad and a GPST3 doctor. All are short term placements, primarily for educational experience, and are considered supernumerary to the clinical workforce. The hospice’s palliative medicine consultant explained that they are an educational supervisor to F2 doctors in training and clinical supervisor for a number of doctors in training. The review team heard that the feedback from F1 and F2 trainees has been positive with mention of the cohesive teamwork in the community care team and inpatient unit. The hospice team explained that they felt this demonstrated that the team work hard to support their doctors in training.

The hospice team reported that they have an amicable relationship with the Chief Executive of Ashford and St Peters Hospital and say they are improving working relationships across the hospital. The hospice team reported that their education and quality team have a multidisciplinary approach both internally and with neighbouring hospices and health providers; they attend weekly teaching and journal clubs with Princess Alice hospice and St Raphael’s Hospice and arrange joint education opportunities with Ashford and St Peter’s Hospitals. It was reported that there is an in-house Clinical Education Programme available to all clinical staff and that attendance and participation at conferences is encouraged and audit and quality improvement projects are supported.

The provision of out of hours cover and educational support was explored. The hospice team explained that their medical rota ensures full medical cover over 24 hours with the palliative medicine consultant first on call together with the locum consultants, the 2 ANPs and another specialty doctor. The recently joined “SHO” will also be joining the on-call rota from November 2023. The hospice team explained that they continue to use Supportive Care UK as the second on call for consultant advice. . When a new member of the team joins the on-call rota, the palliative medicine consultant or the locum consultant is third on call. Should trainees join the on-call rota in the future, we would always ensure that a Palliative Care Consultant is third on call to attend in person should the need arise. The review team asked if the hospice could guarantee that there would be someone available to attend in person if needed by a doctor in training; the hospice team confirmed that they did with currently two, soon to be three, consultants, seven days a week, 365 days a year.

When asked about how well Supportive Care UK can support doctors in training, the hospice senior team said that the team had recently attended a Supportive Care UK talk at Hospice UK conference where it was reported that Supportive Care consultants try to educate doctors in training during their interactions, although this was not contracted. When the review team asked if they could provide assurance on where liability sits if advice to doctors in training is incorrect, the Chief Executive said they would need to look at the terms of liability in their contract with Supportive Care. The Associate Dean explained that, from a deanery perspective, the responsibility should not fall on the doctors in training. See mandatory requirement reference MR-4.

Following the review, the review team received an email from the Palliative Medicine Consultant to explain that their contract with Supportive Care UK states that Supportive Care UK have “no liability for any loss, damage or injury caused by errors, inaccuracies or omissions in any information provided to them by the hospice doctors (including trainees) and that hospice doctors will have their own indemnity.” The Palliative Medicine Consultant explained “regarding the trainees (and by default the hospice’s) liability, then the clinician, in the first instance, would need to document that the advice is remote. If they had concerns, they would need to escalate their concerns re liability to the Responsible clinician within the organisation who had delegated this role to Supportive Care UK.” The Palliative Medicine Consultant clarified that they would inform all future doctors in training hosted at the hospice of this term in the contract with Supportive Care UK as part of their training and “we will support them in understanding when to ask for advice, how to communicate to get the best advice.” The review lead will seek external advice regarding indemnity to determine whether any further assurance is required in relation to this issue.

When asked about the prospect of hosting specialty doctors in training again, the Palliative Medicine Consultant explained that they were trained as an Educational Supervisor (ES) and that the new consultant joining the team in spring 2024 was also an experienced ES. When asked what challenges they could foresee with providing specialty doctors training, the hospice team said that, with the new consultants joining in the spring of 2024, they could not foresee any. They further clarified that with the hospice team as it currently stands, there are occasional days when there is no consultant in the hospice. However, they are available by phone and there are two very experienced ANPs who act as a port of call to offer support. When the new consultant joins in March 2024, there will be 5 day a week consultant on-site cover. See mandatory requirement reference MR-1.

The hospice team were asked about their knowledge of and ability to teach the new dual curriculum for Internal and Palliative Medicine. The Palliative Medicine Consultant explained that they were aware of the new curriculum and potential associated challenges. The hospice team admitted they saw challenges with possible disruption to the hospice, but they were confident the team of consultants expected by spring 2024 would be experienced to cope. The hospice team did not raise any concerns about supervising or supporting trainees following the new dual curriculum. See mandatory requirement references MR2 and MR-3. 

Mandatory requirements

Report approval

Report completed by: Alex Bamford-Blake, Education Quality Project Officer|
Review lead: Dr Catherine Gleeson, Palliative Medicine Training Programme Director
Date approved by review lead: 19 December 2023

NHS England authorised signature: Jo Szram, Postgraduate Dean
Date authorised: 11 September 2024

Final report submitted to organisation: 19 December 2024