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Action Taken
Vocare has reviewed and updated its induction process, including online training availability and improved system training. They have also implemented processes for supervision and mentoring of GP trainees and new GPs, with robust clinical governance processes to identify and address incidents of concern. (AI summary)
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Dear Ms Nolan Thank you for the regulation 28 prevention of future deaths report sent to Vocare following the inquest of Mrs Carol Leeming. Vocare has prioritised our investigation into the issues raised in your report, and we set out below our responses to the concerns you raised which are: (1) There was no requirement for the out of hours GP to have completed induction training prior to starting work for Vocare; (2) There was no facility for online induction training to be made available to new joiners who were unable to attend in person induction training; (3) There was evidence of confusion amongst staff about the functioning and capabilities of the systems in place at the call centre; and (4) Evidence was given at the inquest that there was a regular turnover of different GPs working for Vocare for short periods as part of their training. We note your acknowledgment in your inquest conclusion that the above concerns did not affect the outcome for Mrs Leeming, as the conclusion of the inquest was natural causes, the medical cause of death being 1a) Coronary artery atheroma; 2) Chronic Obstructive Pulmonary Disease. Vocare is an established urgent care provider managing GP out of hours services across the North East and Wearside areas, Yorkshire and Staffordshire as well as managing urgent treatment centres from Berwick to Selby and including the Staffordshire regions. It also provides NHS 111 service for areas of the South East and London and also in Staffordshire. The service is continually scrutinised by our commissioners as well as the CQC which regulates the organisation, to ensure that patient safety is paramount. Key to this is the ability, expertise and welfare of our staff. The service we offer is in line with the NHS England Integrated urgent care service specification [2017, updated 2023] regarding inter alia, the national expectations for the management and prioritisation of ambulance calls, and the defined interoperability standards for interservice transfers. To ensure that staff are fully trained the following systems are in place:
1. There was no requirement for the out of hours GP to have completed induction training prior to starting work for Vocare; KT/DCA/30/11/2023 V2
Totally Cardinal Square West 10 Nottingham Road Derby DE1 3QT
Although it was a requirement for the GP trainee to attend the induction, no alternative dates were offered to him in spite of his repeated requests. Induction sessions were run 6 monthly in line with the GP trainee intakes. However, inductions are now being run quarterly so GP trainees have two options to attend the course and should not be in a position where they have not attended an induction prior to working for the organisation. If they cannot attend then they do not work for us. They do their urgent care training in in-hours surgeries and not in the out of hours period with Vocare. Induction is a pre-requisite to work. The administrative team takes a register of who is at induction and only these doctors are given shifts to work. In addition, following feedback from the attendees it has been agreed that the induction sessions will be run in bite-sized sessions to increase their usefulness. Thus, the induction is divided into 6 slide shows with breaks in-between. The induction covers IT systems and operational matters, thus giving clinicians the tools, they need to ensure that safe high-quality care is delivered.
2. There was no facility for online induction training to be made available to new joiners who were unable to attend in person induction training; Once an individual has completed the physical induction training, there is a facility for the knowledge base online training which reinforces the induction material currently in place via the organisational intranet. However, GP trainees do not obtain access to the intranet until they are provided with their log in details on commencement of their placement. It is anticipated that this online material will be an adjunct to the more frequent, and thus more accessible personal induction sessions which will preclude any starter from commencing work with the organisation where they have not attended a physical induction.
3. There was evidence of confusion amongst staff about the functioning and capabilities of the systems in place at the call centre; Although it is recognised that there is now full interoperability between services in the North East via the use of the PACCs system, there is always the chance that it may fail. All staff have undergone refresher training and are therefore aware of the business continuity plan should this happen. Posters are in situ and reminders have been placed on individual desk tops as an adjunct to this. An improved process for supporting the GP supervisors is in place such that all supervisors fully understand their responsibilities, including shadowing as well completing the portfolio of competency frameworks. It is acknowledged that the organisation works collaboratively with the Deanery in this regard.
4. Evidence was given at the inquest that there was a regular turnover of different GPs working for Vocare for short periods as part of their training. The organisation has two intakes of 30 GP trainees a year. The GP trainees complete 24 hours of work with us in addition to their 6 hours induction and training. This is a block of training and is done within 3 months. A further block of 24 hours is undertaken within the next 3 months which may be with Vocare or with another provider. Feedback from trainees is positive and many apply to join our team when they qualify. The organisation exposes them to many urgent care cases, palliative care cases and give them an understanding of the urgent care system at large. KT/DCA/30/11/2023 V2
Totally Cardinal Square West 10 Nottingham Road Derby DE1 3QT
As an organisation we continually learn and improve our service in tandem with our co providers at North East Ambulance Service. More broadly, Vocare has robust clinical governance processes in place which identify incidents of concern and ensure actions are taken to reduce risk of recurrence. The North East and North Cumbria Integrated Care Board (ICB) with whom we work closely, has oversight of the governance processes. We hope the above gives you assurance that we have and continue to take these issues very seriously. Vocare has effective systems in place to reduce the risk of similar issues recurring by improving our induction, ongoing training and supervision and mentoring of our GP trainees and also any new GP to the organisation. We are not complacent, and we continually review our processes. We will be cognizant of your report when developing and reviewing our pathways to ensure the current high standards are continually maintained.
1. There was no requirement for the out of hours GP to have completed induction training prior to starting work for Vocare; KT/DCA/30/11/2023 V2
Totally Cardinal Square West 10 Nottingham Road Derby DE1 3QT
Although it was a requirement for the GP trainee to attend the induction, no alternative dates were offered to him in spite of his repeated requests. Induction sessions were run 6 monthly in line with the GP trainee intakes. However, inductions are now being run quarterly so GP trainees have two options to attend the course and should not be in a position where they have not attended an induction prior to working for the organisation. If they cannot attend then they do not work for us. They do their urgent care training in in-hours surgeries and not in the out of hours period with Vocare. Induction is a pre-requisite to work. The administrative team takes a register of who is at induction and only these doctors are given shifts to work. In addition, following feedback from the attendees it has been agreed that the induction sessions will be run in bite-sized sessions to increase their usefulness. Thus, the induction is divided into 6 slide shows with breaks in-between. The induction covers IT systems and operational matters, thus giving clinicians the tools, they need to ensure that safe high-quality care is delivered.
2. There was no facility for online induction training to be made available to new joiners who were unable to attend in person induction training; Once an individual has completed the physical induction training, there is a facility for the knowledge base online training which reinforces the induction material currently in place via the organisational intranet. However, GP trainees do not obtain access to the intranet until they are provided with their log in details on commencement of their placement. It is anticipated that this online material will be an adjunct to the more frequent, and thus more accessible personal induction sessions which will preclude any starter from commencing work with the organisation where they have not attended a physical induction.
3. There was evidence of confusion amongst staff about the functioning and capabilities of the systems in place at the call centre; Although it is recognised that there is now full interoperability between services in the North East via the use of the PACCs system, there is always the chance that it may fail. All staff have undergone refresher training and are therefore aware of the business continuity plan should this happen. Posters are in situ and reminders have been placed on individual desk tops as an adjunct to this. An improved process for supporting the GP supervisors is in place such that all supervisors fully understand their responsibilities, including shadowing as well completing the portfolio of competency frameworks. It is acknowledged that the organisation works collaboratively with the Deanery in this regard.
4. Evidence was given at the inquest that there was a regular turnover of different GPs working for Vocare for short periods as part of their training. The organisation has two intakes of 30 GP trainees a year. The GP trainees complete 24 hours of work with us in addition to their 6 hours induction and training. This is a block of training and is done within 3 months. A further block of 24 hours is undertaken within the next 3 months which may be with Vocare or with another provider. Feedback from trainees is positive and many apply to join our team when they qualify. The organisation exposes them to many urgent care cases, palliative care cases and give them an understanding of the urgent care system at large. KT/DCA/30/11/2023 V2
Totally Cardinal Square West 10 Nottingham Road Derby DE1 3QT
As an organisation we continually learn and improve our service in tandem with our co providers at North East Ambulance Service. More broadly, Vocare has robust clinical governance processes in place which identify incidents of concern and ensure actions are taken to reduce risk of recurrence. The North East and North Cumbria Integrated Care Board (ICB) with whom we work closely, has oversight of the governance processes. We hope the above gives you assurance that we have and continue to take these issues very seriously. Vocare has effective systems in place to reduce the risk of similar issues recurring by improving our induction, ongoing training and supervision and mentoring of our GP trainees and also any new GP to the organisation. We are not complacent, and we continually review our processes. We will be cognizant of your report when developing and reviewing our pathways to ensure the current high standards are continually maintained.