Dean s Performance and Quality Review Hertfordshire Partnership University NHS Foundation Trust June 2013 This report summarises the findings and recommendations of the Multi-Professional Dean s Performance and Quality Review to Hertfordshire Partnership University NHS Foundation Trust on 27 th June 2013 in line with Health Education East of England Quality Management Framework Page 1 of 14
DOCUMENT HISTORY Version Date Remarks 1.0 27/06/13 Initial draft 1.1 02/07/13 CB/FMS 1.2 10/07/13 JW 1.3 17/07/13 Further revisions 2.0 29/07/13 Final version Contents Page 1.0 Introduction 3 2.0 Visit team 4 3.0 Existing reports 4 4.0 Context, organisation and structure of report 5 5.0 Non-Medical Education and Training 6 6.0 Medical Education and Training 8 6.1 Domain 1 Patient safety 8 6.2 Domain 2 Quality management, review and evaluation 9 6.3 Domain 3 Equality, diversity and opportunity 9 6.4 Domain 4 - Recruitment 9 6.5 Domain 5 Delivery of approved curriculum including assessment 10 6.6 Domain 6 Support and development of trainees, trainers and local 10 faculty 6.7 Domain 7 Management of education and training 11 6.8 Domain 8 Education resources and capacity 11 6.9 Domain 9 Outcomes 12 7.0 Decision of Deanery Quality Team regarding Medical Education 12 & Training 8.0 Medical Conditions 12 9.0 Multi-Professional Recommendations 13 10.0 Notable Practice 14 Page 2 of 14
1.0 Introduction 1.1 The Directorate of Education and Quality of HEEoE commissions and quality manages postgraduate medical, dental and healthcare education on behalf of and within the area served by Health Education East of England. It does so within the Corporate and Educational Governance systems of Health Education East of England and to the standards and requirements of the General Medical Council (GMC), General Dental Council (GDC) and the Nursing and Midwifery Council. These processes are outlined in the HEEoE Directorate of Education and Quality Management Framework for medical and dental education and Quality Assurance Framework for other healthcare education. 1.2 Quality management uses information from many and varied sources that triangulate evidence against standards of the quality of education and training within local education providers and across the east of England. These sources include student, trainee and trainer surveys, the Performance and Quality Assurance Framework (PQAF), panel feedback (e.g. ARCP), hospital and public health data (e.g. HSMR), visits by specialty colleagues and Dean s Performance and Quality Review visits (formerly known as Dean s Visits and Deanery Performance and Quality Reviews) that may be planned or triggered by concerns or events. 1.3 Whilst the quality management processes of HEEoE Directorate of Education and Quality incorporate information from many sources, it is explicit that the primary purpose of the Dean s Performance and Quality Review is the quality management of non-medical and medical education and training. The visit is not designed to, nor capable of, providing a thorough assessment of the quality of care provision. Moreover, if concerns are identified, these are passed on to those responsible. 1.4 This report is of a planned Dean s Performance and Quality Review assessing non-medical and medical education and training in the provider, and is not a response to any concerns. 1.5 This report is based on sampling via surveys and visits and is not therefore exhaustive. The findings are provided with the caveat that any further conclusions that are drawn and action taken in response to those conclusions may require further assessment. 1.5 The Trust is required to provide an action plan by 27 th September 2013 and to complete actions agreed within the specified time periods. Progress will be monitored as part of the Learning Development Agreement contract monitoring and on-going quality management under the leadership of Health Education East of England Quality Management Group chaired by the Deputy Dean (Quality). A formal update on the action plan is required by 27 th December 2013 unless otherwise stated under the conditions section below. Page 3 of 14
2.0 Visit team 2.1 Lead Visitor: Dr Jonathan Waller, Head of Medical Programmes and Deputy Postgraduate Dean - Quality 2.2 Visitors: Professor John Howard, Deputy Postgraduate Dean and Postgraduate GP Dean Chris Birbeck, Head of Quality and Improvement Susan Agger, Quality and Academic Training Manager Dr Chris O Loughlin, Head of Medical Education, Cambridgeshire & Peterborough NHS Foundation Trust Dr Claire Lawton, Consultant Psychiatrist, Cambridgeshire & Peterborough NHS Foundation Trust Fiona McMillan-Shields, Deputy Director of Nursing Quality, Herts & South Midlands Area Team Gareth George, Deputy Director, Bedfordshire and Hertfordshire Workforce Partnership Alan Makepiece, Education Lead, Bedfordshire and Hertfordshire Workforce Partnership Mary Benfield, Lay Representative Dr Tarun Sehgal, Trainee Representative Agnès Donoughue, Quality Co-ordinator 3.0 Existing reports referred to prior to and during the visit 3.1 GMC Trainee Survey Reports 2009, 2010, 2011, 2012 and 2013 GMC Trainer Survey Reports 2010 and 2011 Additional GMC Training Surveys documentation 3.2 Head of Psychiatric Training s reports 2012 and 2013 3.3 Non-medical quality documentation: PQAF Improvement Action Plan 2013/14 Academic Review of Practice Partners: Education Quality Assessment Document 2012 PQAF Practice Self-Assessment EQuAD Report 2012 Pre-Registration Survey: Education Quality Assessment Document 2012 Post-Registration Survey: Education Quality Assessment Document 2012 3.4 CQC reports 2011, 2012 and 2013 Summary of SIs April 2012 June 2013 3.5 Additional documentation provided by the Trust: HPFT Medical Education Structure Psychiatric Tutors Meeting agenda & minutes Trust Clinical Supervisor Report and placement review documents Clinical & Educational Supervisors along with supervision and equality & diversity training records Education and Equity & Excellence completed report 2013-07-08 LEP / Trust Medical Education Report 2012 Page 4 of 14
LEP / Trust Medical Education Report 2011 Report on the Hertfordshire Training Scheme in Psychiatry prepared for the Eastern Deanery (2008) Trust Medical Education Report for the Deanery (2009) Psychiatric Training Report (2012-2013) presented at the Medical Staff Committee meeting Psychiatric Training Report (2011) presented at the Medical Staff committee meeting HPFT Medical Education Strategy for Psychiatry Training (2010-2011) presented at the Medical Staff Committee meeting Medical Education update and review (2008-2009) presented at the Medical Staff committee meeting Update on Medical Education in HPFT (March 2009) presented at the Medical Staff committee meeting ARCP outcomes for HPFT psychiatric trainees (2011-2012) Royal College of Psychiatrists: Clinical & Educational Supervision course (15 th March 2013) Attendance list & evaluation Royal College of Psychiatrists: Clinical & Educational Supervision course (29 th March 2012) Attendance list & evaluation Royal College of Psychiatrists: 3 rd Clinical & Educational Supervision workshop (24 th November 2010) Attendance list & evaluation Royal College of Psychiatrists: 2 nd Clinical & Educational Supervision workshop (24 th February 2010) Attendance list & evaluation Royal College of Psychiatrists: 1 st Clinical & Educational Supervision workshop (23 rd September 2009) Attendance list & evaluation Trainees MRC Psych Examination successes and consultant appointments since 2008 Publications involving psychiatric trainees Audits with summary of trainee involvement Training posts with names of clinical supervisors Induction programmes: Trust-wide and local programmes Medicines Management Education & Training Programme Mental Health Modular Training for General Practitioners Library Locality Academic Programme/MSC Programme Others Awards, Committees 4.0 Context, organisation and structure of report 4.1 This Dean s Performance and Quality Review was undertaken at a time when the Trust was in an unprecedented state of reorganisation including radical changes to the configuration and delivery of its services. As a consequence, it has occurred at a time of great uncertainty for employees of all professions and levels of seniority. The Trust is fully aware of these current challenges and is clearly seeking to address them in a timely fashion. This report therefore has to be read and understood in this context but will make whatever recommendations are necessary to protect patient safety and the quality of education and training. Page 5 of 14
4.2 The report first provides an overview of the non-medical feedback in the context of the five key performance indicators (KPIs) that inform the PQAF in section 5.0. The subsequent section 6.0 outlines the findings within the General Medical Council s generic standards for training where applicable. The Quality Team decision in relation to medical education and training is in section 7.0. Medical conditions are in section 8.0. Multi-Professional recommendations and notable practice are in sections 9.0 and 10.0. 5.0 Non-medical education and training KPI KPI One Education Governance The organisation is assured that they have robust education governance in place Feedback from Review Clear evidence of organisational educational governance arrangements that appeared to be understood by staff. The integrated approach, that was demonstrated at the Trust s presentation, also appears to reflect how the approach has been implemented e.g. there appears to be an obvious relationship between Trust strategy, the mentors and the students who they support. KPI Two Learning Environment The organisation provides high quality learning environments for students Page 6 of 14 Good evidence of multi-disciplinary working and learning especially in some community settings where the students reported a more integrated approach to working and learning. Good evidence of partnership working and support with the HEI, with students reporting regular contact with the Clinical Tutors and Education Champions. Many students also stated that the HEI Tutors and their placement mentors have been very supportive with assignments and projects. Students reported little faith that any of the feedback that they submitted on their programme experience would lead to changes in the programme, so they were non-compliant with survey requests. The mentors stated that they were all actively involved in the delivery of the PQAF action plans. Good access to the Trust s intranet and other IT platforms to enable students to keep up to date with latest guidelines. Access to Library and knowledge resources also appeared good. Students reported that when there had been clinical incidents e.g. a client event requiring de-escalation, the staff had been very
KPI KPI Three Quality of Care Students are adequately prepared by the provider organisation to deliver high quality care KPI Four Student Support / Education / Assessment Students are effectively supported, educated and assessed by the provider organisation Feedback from Review proactive in reviewing the event with the students and this had been a great learning experience. In contrast, students reported that they often were involved in the Trust Incident reporting process but were unclear what happened to the forms and what the impact of this was on the service delivery i.e. lessons learnt. Whilst we heard that junior doctors had opportunities to participate in Trust-wide committees, this did not seem to be the case with the students we spoke to. Induction processes appear to be good and students reported a high degree of compliance and attendance. Compliance with annual mandatory training also appears good, however it was reported that none of the students had received training in breakaway apart from a theory session in the HEI at the beginning of their training. Good levels of support available to ensure the appropriate use of Trust documentation. All students were aware of the processes to ensure Safeguarding and Deprivation of Liberties were applied when appropriate. Very positive feedback from the students about the mentor arrangements. All of the students (nursing, social work and OT) recognised that the organisational transformation programme has had a negative impact on the morale of some of the substantive staff members. Despite this, other staff have ensured that students have felt supported and achieved their learning outcomes. Mentors reported having good opportunities for support and professional development from the organisation. In OT and Social Work, the mentors explained that, as lone workers or within very small teams, taking on responsibility for a student was often a challenge and this had been compounded by the perceived insecurities relating to the organisation changes. Page 7 of 14
KPI Feedback from Review The community-based mentors stated that they had great access to laptops and remote working which meant that they were able to increase the learning in opportunities for the students, as the mentors were not tied up with administration issues. The mentors were aware of the local and national arrangements to quality assure the mentors in the Trust. The Trust has employed their own Practice Education Facilitator who had had a positive impact on the learning environment through the support he offers to the mentors and the HEIs. Students reported that they had received mixed messages from the Trust in relation to opportunities for future employment which had a negative impact on their final placements. KPI Five MPET Investment Provider organisations demonstrate effective utilisation of the Multi- Professional Education and Training Levy (MPET) investment Good usage of the investment with a total spend of 98.5% of budget on a range of multi-professional training and development opportunities. 6.0 Medical and Dental Education and Training 6.1 Domain 1 Patient Safety 6.1.1 The Trust provides both Trust-wide and site specific induction for all trainees including those who start out of phase. This is supplemented by an online induction booklet and an online survival guide for trainees. However, the trainees met reported that it is inconsistent and not all trainees receive sufficient induction before their first on-call. In particular, the visiting team was concerned that care records training was sometimes given after induction and after the trainees had started to see patients. 6.1.2 Whilst the trainees raised some concerns regarding handover, the Trust is exploring an online solution to ensure the necessary information is available. The trainers raised some concerns regarding handover at the Lister and QE2 sites in the morning which is inconsistent and could give rise to patient safety issues. Pending an e-solution to this issue, the Trust needs to address this potential patient safety issue as a matter of urgency. Page 8 of 14
6.1.3 In common with many mental health trusts, the first on-call trainee is expected to cover multiple sites (6 in the East and 18 in the West) and this can involve the expectation of travel between these sites at any time of the night, raising safety concerns for the trainee and patient safety issues. This issue has only arisen since the number of doctors resident on call was reduced from four to two. The Trust must address this for the next cohort of trainees. 6.1.4 There is evidence that the system for SI reporting is well understood within the Trust but there is inconsistent evidence in the feedback, reporting and learning from serious incidents. 6.1.5 The visiting team noted with concern in the trainees free text comments within the 2013 GMC NTS reports of undermining and harassment and consequent high sickness rates. However, the trainees interviewed did not express similar concerns. 6.2 Domain 2 Quality management, review and evaluation 6.2.1 There has been excellent engagement with HEEoE quality management processes including the QM3 Head of Psychiatric Training s Report and supporting evidence. The Quality Matrix has been fully completed although its value would have been enhanced by closer correlation of exact percentages achieved since it is noted that the excellent evidence presented in support of the matrix was at minor variance in some areas. 6.2.2 The Trust is to be commended for its engagement with the DPQR visit process. 6.2.2 Whilst the Trust achieved a 93.62% response rate in the GMC Survey 2013, it is noted that this was, in fact, the lowest achieved percentage by an HEEoE Trust. 6.3 Domain 3 Equality, diversity and opportunity 6.3.1 The Trust has commendable levels of Equality & Diversity amongst its clinical and educational supervisors although it is noted that two of them do not currently meet the required standard. 6.3.2 Training in Safeguarding children and adults has been documented at 100% for trainees. 6.4 Domain 4 Recruitment 6.4.1 The Trust is commended for its engagement with HEEOE as a Lead Provider for recruitment to CT1 Psychiatry. Page 9 of 14
6.5 Domain 5 Delivery of approved curriculum including assessment 6.5.1 The visiting team was impressed by the Trust s achievement of University status in collaboration with the University of Hertfordshire and the many multiprofessional initiatives for education and training that have been developed as a consequence of this; in particular, the development and delivery of a truly multi-professional Masters Degree Course is an example of truly notable practice which should serve as a model to which others should aspire. 6.5.2 Core Psychiatry Training is a negative outlier in the GMC Trainee Survey 2013 in the areas of educational supervision, local teaching and access to educational resources. It was reported that the Trust was aware of these issues and was in the process of addressing the recognised areas for improvement. 6.5.3 The visiting team noted with concern the closure of the Trust s addiction service and the impact this may have on delivery of this aspect of the curriculum and the ability to offer an endorsement in higher training. The Trust needs to be aware of the requirement for this aspect of the curriculum to be provided in collaboration with others if it cannot be provided locally. 6.5.4 The visiting team noted with interest the provision of a biannual senior traineeled MRC Psych examination preparation programme. The senior trainees also deliver a monthly academic programme for more junior trainees. 6.5.5 The Trust provides an active clinical audit programme with demonstrable trainee involvement. 6.5.6 The Trust is commended on offering more F1 places from August 2013 and a Taster week. 6.5.7 GPST trainees reported high levels of satisfaction with their training which correlates well with the 2012 GMC Survey. 6.6 Domain 6 Support and development of trainees, trainers and local faculty 6.6.1 The Trust has in place the necessary foundation for the appropriate selection, training and appraisal of its clinical and educational supervisors. However, this will need to be significantly enhanced in the light of the requirements of the GMC for this process to directly abide by the AoME standards and domains specified by the GMC that need to be fully in place by 2016. 6.6.2 Currently the provision of sufficient time and resource for educational supervision within consultant job plans meets the GMC recommended level of 0.25 PA per trainee per week. 6.6.3 The Trust is to be commended for its comprehensive database on the training and development of its educational and clinical supervisors. Page 10 of 14
6.6.4 The Trust demonstrates excellent commitment to the continued development of its specialty doctors with an active SAS Tutor. This support is exemplified by the ability of one of its specialty doctors to be supported to undertake research for a higher degree with the University of Hertfordshire. 6.6.5 The visiting team noted the Trust s commitment to active and meaningful engagement with trainees at multiple levels within the Trust including the appointment of a Quality Improvement Fellow and a Senior Resident. Trainee representation is in place for the majority of relevant committees in the areas of both service delivery and education and training. The Trust provides mentoring for all its trainees. In addition, there is an innovative coaching network as well as access to leadership training. 6.6.6 The Trust is to be commended on the development and delivery of a training programme in mental health for GPs and the Trust s role as an Academic Centre for Learning Disabilities. 6.6.7 The visiting team commends the Trust for the development of trainees in the educational infrastructure in the University of Hertfordshire. The visitors also noted the Recovery MSc which has received EU funding. 6.7 Domain 7 Management of education and training 6.7.1 There is clearly an ethos of commitment to education and training within the Trust and this is exemplified by its recent attainment of University status and the multi-professional spectrum of educational initiatives that the visiting team encountered during the course of the comprehensive Trust presentations. 6.7.2 The Trust has in place a comprehensive governance structure for education and training including Board level engagement. 6.7.3 There is strong and effective multidisciplinary leadership of education and training within the Trust at all levels. 6.7.4 The visiting team notes the appointment of a Non-Medical Clinical Tutor under the Equity and Excellence HEEoE programme. 6.8 Domain 8 Educational resources and capacity 6.8.1 The GMC NTS 2013 recorded high levels of concern amongst trainees with regard to their ability to access educational resources. The Trust is aware of the current deficiencies and a programme to relocate the Postgraduate Centre is progressing. 6.8.2 Despite the geographical challenges, the trainees reported good access to libraries. Page 11 of 14
6.9 Domain 9 Outcomes 6.9.1 The Trust is commended for its excellent achievement in the award to 10 trainees of an MSc in Psychiatry Practice as the first cohort to have completed the full course. In addition, the high success rate in the MRC Psych examination is noted. 7.0 Decision of Deanery Quality Team in relation to medical education and training 7.1 The provision of medical education and training at Hertfordshire Partnership University NHS Foundation Trust has: Met with conditions the requirements of Health Education East of England Directorate of Education and Quality under the standards required by the General Medical Council and therefore is given conditional approval for three years. 7.2 An action plan is required by 27 th September 2013 including confirmation of completion of actions on the immediate conditions, if applicable. 7.3 A formal update on the action plan is requested by 27 th December 2013. 7.4 Specialty Training Programme School formative visits will continue with their planned frequency and, subject to the findings of those visits, routine visits will continue. 7.5 Subject to 7.2, unless otherwise triggered, the next full Dean s Performance and Quality Review will be in June 2016. 7.6 The monitoring of the implementation of action plans will be through the Head of School of Psychiatry reporting to the Deputy Postgraduate Dean for Quality. 8.0 Medical Conditions 8.1 Whilst the trainees raised some concerns regarding handover, the Trust is exploring an online solution to ensure the necessary information is available. The trainers raised some concerns regarding handover at the Lister and QE2 sites in the morning which is inconsistent and could give rise to patient safety issues. Pending an e-solution to this issue, the Trust needs to address this potential patient safety issue as a matter of urgency. [domain 1] (by 30 th July 2013) 8.2 In common with many mental health trusts, the first on-call trainee is expected to cover multiple sites (6 in the East and 18 in the West) and this can involve the expectation of travel between these sites at any time of the night, raising safety concerns for the trainee and patient safety issues. This issue has only arisen since the number of doctors resident on call was reduced from four to Page 12 of 14
two. The Trust must address this for the next cohort of trainees. [domain 1] (initial action plan by 30 th July 2013; 3 months) 8.3 The Trust has commendable levels of Equality & Diversity amongst its clinical and educational supervisors although it is noted that two of them do not currently meet the required standards. The Trust must ensure that all its supervisors have received Equality & Diversity training. [domain 3] (3 months) Multi-Professional feedback 9.0 Recommendations 9.1 The visiting team was concerned that care records training was sometimes given after induction and after the trainees had started to see patients. The Trust must ensure that care records training forms part of induction and happens before trainees start seeing patients. 9.2 There is evidence that the system for SI reporting is well understood within the Trust but there is inconsistent evidence in the feedback, reporting and learning from serious incidents. The Trust must ensure that trainees receive feedback from serious incidents in a timely fashion and that the process for reporting and learning from serious incidents is well understood by the trainees. 9.3 The Quality Matrix has been fully completed although its value would have been enhanced by closer correlation of exact percentages achieved since it is noted that the excellent evidence presented in support of the matrix was at minor variance in some areas. The Trust would benefit from enhancing the evidence provided in support of the quality matrix including the provision of percentages. 9.4 Core Psychiatry Training is a negative outlier in the GMC Trainee Survey 2013 in the areas of educational supervision, local teaching and access to educational resources. It was reported that the Trust was aware of these issues and was in the process of addressing the recognised areas for improvement. The Trust should address the negative outliers in Core Psychiatry as identified in the GMC Training Survey 2013 through its action plan following this visit, where appropriate, and in the QM3 report by the Head of Psychiatric Training. 9.5 The visiting team noted with concern the closure of the Trust s addiction service and the impact this may have on delivery of this aspect of the curriculum and the ability to offer an endorsement in higher training. The Trust needs to be aware of the requirement for this aspect of the curriculum to be provided in collaboration with others if it cannot be provided locally. Page 13 of 14
The Trust should address the lack of addiction service training to ensure that this aspect of the curriculum is fulfilled and that trainees can access this training if it cannot be provided locally. 9.6 The Trust has in place the necessary foundation for the appropriate selection, training and appraisal of its clinical and educational supervisors. However, this will need to be significantly enhanced in the light of the requirements of the GMC for this process to directly abide by the AoME standards and domains specified by the GMC that need to be fully in place by 2016. The Trust should develop and enhance its processes for the selection, training and appraisal of its supervisors in the light of the requirements specified by the GMC. 9.7 The GMC NTS 2013 recorded high levels of concern amongst trainees with regard to their ability to access educational resources. The Trust is aware of the current deficiencies and a programme to relocate the Postgraduate Centre is progressing. The Trust should ensure that it addresses the issues surrounding access to educational resources as highlighted in the GMC Training Survey 2013. 9.8 The Trust should improve the feedback given to students and the clinical areas following the reporting of clinical incidents. 9.9 The Trust should review the content of its mandatory training to include breakaway training as a number of students had only had the theoretical component. 10.0 Notable Practice 10.1 The visiting team was impressed by the Trust s achievement of University status in collaboration with the University of Hertfordshire and the many multiprofessional initiatives for education and training that have been developed as a consequence of this, in particular the development and delivery of a truly multi-professional Masters Degree Course is an example of truly notable practice which should serve as a model to which others should aspire. 10.2 The consistently reported high levels of satisfaction experienced by GPST trainees is an example of notable practice. 10.3 The Trust s own Practice Education Facilitator was recognised as an excellent resource for both the students and the mentors. Signature of Lead Visitor Dr Jonathan Waller Deputy Postgraduate Dean - Quality 29 July 2013 Page 14 of 14