MEDICAL SCHOOL ADMINISTRATION
ROYAL FREE AND UNIVERSITY COLLEGE MEDICAL SCHOOL
QUALITY ASSURANCE SIFT VISIT
TO UNIVERSITY COLLEGE LONDON
HOSPITALS NHS FOUNDATION TRUST
7th July 2006
CONTENTS
Page
Executive summary 2
Findings
Good Practice
Next Steps
List of Participants 3
Action Plan 4
1. Background 5
Scope
Method
2. Induction & timetabling 6
3. Clinical Teaching 6
Introductory Course to Clinical Method (ICCM)
General Medicine and Specialties (formerly GEDNOH)
General Medicine and MiC
AAU, Acute Medicine and clinical Pharmacology
COOP & Rheumatology
Dermatology
Pathology
4. Assessment 8
5. Welfare/pastoral - procedures for students causing concerns 8
6. Resources 8
Space
AV & IT
Lockers
Access
Library
7. SIFT 9
Consultant Teachers
Liaison with the Medical School
8. Quality Assurance, Staff Development and Appraisal 9
9. Summary 10
EXECUTIVE SUMMARY
The Medical School and University College Hospital share a lengthy and illustrious
history with many generations of undergraduates deriving enormous benefit from the high
quality clinical teaching.
Since moving to new premises in 2005 the student experience has suffered, despite the
good quality clinical teaching, due to significant lack of basic facilities.
This problem was foreseen by the GMC in their 2005 Quality Assurance Report which
required the School to ensure a satisfactory response to their concerns in order to ensure
continuing educational approval with the Privy Council.
The School’s annual report to the GMC (due end October 2006) must outline any
progress in ensuring adequacy of teaching facilities at UCLH.
FINDINGS
The teaching at UCLH is of a high standard and valued by students. There is evidence of
good practice in a number of firms but some modules have problems relating to capacity,
continuity or session cancellation.
The Trust is in breech of the Service Level Agreement in relation to teaching facilities and
Trust funded administrative support. The School will be seeking advice from the SHA.
The management culture of the Trust has not appeared to support directly undergraduate
teaching although new appointments may help to improve this. Greater transparency
regarding the use of SIFT is needed, particularly in relation to facilities and consultant job
planning and appraisal.
The Medical School wishes to work with the Trust to improve communication and
planning during times of change.
GOOD PRACTICE
The quality of bedside teaching was commended on many firms with Medical Specialties
and COOP singled out for praise.
Students highlighted the educational quality of the joint Rheumatology and Orthopaedics
timetable and teaching.
The COOP firm takes special care to ensure students and staff can maintain contact in
case of queries or timetable changes – this is much appreciated by students.
Students in the Thyroid clinic can see their own patients and are invited to contribute to
the clinic management meeting.
Assessment carried out by named mentors, or based on the collated views of a number
of teachers, have greater credibility and educational value for students.
Despite the lack of specific facilities for undergraduates, the new hospital is well-
equipped and an excellent clinical environment that will, eventually, enhance the
students’ learning experience.
Dr Jean McEwan has been invaluable in raising the needs of students in the Trust.
NEXT STEPS
The Action Plan lays out the points to be addressed by each party and jointly. The School will
liaise with the SHA regarding failure to complete urgent actions that breech the SLA.
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LIST OF PARTICIPANTS
QUALITY ASSURANCE SIFT TEAM
Prof Jane Dacre (JD) Director of Medical Education [Chair]
Dr Anita Berlin (AB) Sub Dean, Quality
Dr Bulend Yuksel (BY) Undergraduate Tutor, Barnet & Chase Farm NHS Trust
Dr Aroon Lal (AL) Associate Director of Undergraduate Education, Basildon & Thurrock
University Hospitals NHS Foundation Trust
Mr Lee Walker (LW) SIFT Co-ordinator
Ms Ann Glasser (AG) QA Officer
Mrs Sabine Morris (SM) Year 3 Administrator
CONSULTANTS & OTHER STAFF
Dr Jean McEwan (JMcE) Director of Clinical Teaching, Site Sub Dean (Bloomsbury
Campus)
Dr Ray McAllister (RM) Acting Head, Division of Medicine and Acute Medicine
Dr Paul Glynn (PG) Director Emergency Services and Medicine
Dr Aroon Hingorani (AH) Clinical Pharmacology
Dr Raymond Yu (RY) Dermatology
Dr Jerry Brown (JB) Respiratory
Dr Adrian Wagg (AW) Care of the Older Person (COOP)
Dr Stephanie Baldeweg (SB) Endocrinology and Diabetes
Dr Kwee Yong (KY) Haematology
Dr Anisur Rahman (AR) Rheumatology
Prof John Betteridge (JB) Endocrinology and Diabetes
Prof Alistair Forbes (AF) Gastroenterology
REPRESENTATIVES OF UCLH NHS FOUNDATION TRUST
Mr Robert Naylor (RN) Chief Executive, UCLH NHS Foundation Trust (sent apologies)
Prof Tony Mundy (TM) Medical Director
Mr Mike Foster (MF) Director of Finance
Mr David Amos (DA) Director Human Resources
The Medical School Team would like to thank Dr Jean McEwan for all her help with planning
and organising the day‘s schedule as well as all the staff and students whom they met.
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Action Plan (E = Essential, D = Desirable)
ACTIONS FOR TRUST ACTION TO BE TAKEN WHO BY WHEN
To:
E 1. Provide administrative support for clinical teachers in line with the SLA TM immediate
E 2. Provide lockers in line with the SLA TM URGENT
E 3. Increase the amount of available teaching space by reviewing seminar room booking TM URGENT
system, prioritising clinically relevant teaching in meeting rooms adjacent to ward
areas
E 4. Improve facilities in meeting rooms to include projectors and PCs TM Jan 07
D 5. Implement and review the plan to have a rota for supervising students in AAU JME immediate
D 6. Ensure wherever possible, larger out-patient consulting rooms for OP specialties TM immediate
such as Dermatology
E 7. Build review of teaching into job appraisals using QA data available from the School TM/DA immediate
E 8. Arrange reader access to the clinical database for students, following provision of an JME immediate
annual Data Protection lecture
D 9. Include a clear statement regarding the presence of RFUCMS students in the JME immediate
hospital and the implications of their training for patients on the Trust website
E 10. Consult with the Medical School on the immediate and long term implication of ward RN immediate
closures or contract changes on teaching as per the SLA
ACTIONS FOR SCHOOL ACTION TO BE TAKEN WHO BY WHEN
To:
E
1. Provide student lists with photos to improve accuracy of assessment and identifying
“at risk” students
2. Promote regular use of the Evaluation Website by clinical teachers, module leads
D
and the Site Sub Deans
E 3. Write to Tony Mundy regarding Dr Nandini Shetty’s teaching arrangements
E 4. Contribute proactively to planning discussions about further building works
JOINT ACTIONS FOR SCHOOL & TRUST ACTION TO BE TAKEN WHO BY WHEN
To:
E
1. Organise a follow-up meeting for AB or JD and LW with JMcE and TM with a view of
re-establishing a regular Liaison Group or Committee
E 2. Review the staff-student ratio on some firms
E
3. Discuss with the SHA sanctions or penalties for ongoing non compliance with the
SLA
E 4. Ensure adequate undergraduate teaching facilities are provided in the next phase of
the UCLH development through consultation between the Trust and the School
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1. BACKGROUND
The aim of the Quality Assurance/SIFT site visits is to appraise the current teaching and
educational facilities provided by the Trust, to identify good practice and ways in which the
Trust and the Medical School can improve the educational experience of undergraduates for
the Royal Free and University College Medical School placed in the Trust.
The Department of Health has indicated likely changes to the provision of SIFT so this visit
was an opportunity to highlight the strengths of the provision of teaching and the areas in
need of support or improvement. The UCLH NHS Foundation Trust receives over £20m of
SIFT each year for providing undergraduate teaching.
The Medical School and University College Hospital share a lengthy and illustrious history.
Many generations of undergraduates have derived enormous benefit from the high quality
clinical teaching provided in the hospital. The Trust’s website states that:
"UCLH is committed to delivering top quality patient care, excellent education and
world class research."
Since moving to new premises in 2005, despite the ongoing efforts of many clinicians, the
student experience has suffered due to significant lack of basic facilities (teaching space,
lockers, IT and AV equipment). These problems were foreseen by the GMC in their Quality
Assurance Report (QABME) in 2005 as a result of which the School is required to ensure a
satisfactory response to the GMC concerns in order to ensure continuing approval by the
Privy Council for the School to provide basic medical education.
GMC Requirement
“Paragraph 35. Clinical academic and other staff expressed reservations about the
extent of teaching space available at the new site. Students also commented that
they felt they were competing for teaching space with postgraduate trainees and
others. The School reported that they are working very hard with UCLH on this
issue.
Paragraph 76. The GMC would wish to receive an update on the adequacy of
teaching space at UCLH from the School in the 2006 follow up report.” [Due end
October 2000]
QABME RFUCMS Final Report GMC
2005
SCOPE
Due to the large numbers of students, visits to central teaching Trusts this year focus solely
on the provision of teaching of Medicine and Medical Specialities in Year 3 and Dermatology
(Year 4).
METHOD
Evidence and information gleaned from the following sources form the basis for this report
and the Action Plan.
Prior to the visit the team from the Medical School appraised:
• pre-visit documentation provided by the lead consultants and the Site Sub Dean
• firm timetables
• course guides and log books
• SIFT allocations
• student feedback on teaching
• the UCLH Trust Website
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During the visit the Team met with:
• Site Sub Dean
• lead consultants
• representatives from the Trust
• a group of students
The Team were also given a tour of some of the teaching facilities.
2. INDUCTION, TIMETABLING & ADMINISTRATION
Timetabling and inductions to firms work well with especially positive feedback regarding
Orthopaedics/Rheumatology. Some students find travelling to St Pancras Hospital to attend
the COOP firm a challenge. Cancellations are significant in some modules with over 30% of
students reporting 4 or more cancelled sessions in the Medical Specialty module. Module
administration is good and students had no complaints. However Trust-funded administrative
support is very limited. Acute Medicine and Cardiology has one session of College-funded
administration, all other firms reported inadequate or non-existent administrative support
although this is a specified requirement of the Service Level Agreement (SLA). It was also
noted that there is no mention of the presence of medical students on the Trust website
which seems a missed opportunity to communicate part of its educational mission to the
general public.
3. CLINICAL TEACHING (BEDSIDE TEACHING, OUT-PATIENTS, WARD ROUNDS, CONSUTLANT FIRMS)
Students are very positive about their clinical experience in all firms at UCLH and this is
supported by the on-line evaluation data. Apart from cancellations they are content with the
quantity and quality of the teaching – particularly at the bedside. They would however
appreciate more direct observation and feedback on their learning needs and skills on some
firms.
Students observed that teaching at UCLH is more consultant-led with juniors less involved
than at the Royal Free, with the exception of Infectious Diseases where they spent a week
shadowing an F1 doctor. From August the Trust will be reorganising the junior doctors which
should help support student teaching. This will be monitored in the student feedback.
The firm structures vary and students sometimes find it difficult to identify a named mentor or
assessor. This is compounded by fractured timetables, attempts to give students broad
experience in highly specialised firms and the layout of the hospital and wards (with no
central locations (e.g. a nurses’ station or teaching rooms). The failure to provide appropriate
facilities, in particular teaching space adjacent to clinical areas, access and lockers, is
addressed in Section 6. However it should be noted here that inadequate facilities have had
a significantly adverse impact on what should be a very positive learning opportunity for
students.
Introductory Course to Clinical Method (ICCM): No issues.
General Medicine and Specialties: All firms performed well although Dr Webster’s and
Professor Stewart’s firms stand out in the student feedback as exceptional. The
Endocrinology firm is well structured and there are plans to provide more formal sessions.
KY runs the Haematology firm as well as providing Haematology teaching in all other years
representing a very significant individual burden. Students report this is a good firm with very
dedicated staff but many clinics are highly specialised and repetitive. Students reported that
Monday afternoon teaching was often cancelled and lack of exposure to acute medicine was
highlighted by students and teachers as a concern. Overall clinical teachers enjoy teaching
but reported “we are at the limit of what we can do” because of staff-student ratios and lack
of administrative support.
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General Medicine and MIC (Cardiology / Respiratory): Student feedback on General
Medicine and MiC teaching is very good, with JB being singled out for praise. The main
student issues are the perception that students are not all having the same clinical exposure
and on-line feedback indicates a high rate of cancellations (especially for Respiratory
teaching) in some blocks. Respiratory teachers feel they offer a reasonable taster by moving
students around different chest firms but this timetable means many teachers may only see
each student once and coupled with the number of students this limits the attention they
each receive. Student lists with photos may help consultants identify students, especially
poor attenders and underperformers
Changes in the Cardiology timetable have led to excellent feedback with the aim of ensuring
students see general cases as well as some acute patients. JMcE continues to work on
improving the clinical exposure. Students appreciate the superior facilities at the Heart
Hospital. All teachers noted that the student’s own attitude to directing their learning is key in
making the most of the opportunity offered in cardiology at the Heart and UCL Hospitals.
Clinical Pharmacology and AAU/Acute Medicine: The Clinical Pharmacology team
receives excellent feedback with high levels of consultant involvement and daily clinical
teaching. Nonetheless, the students spend only two weeks (another week being devoted to
ENT teaching) in the attachment and consultants feel that it is now difficult to keep an eye on
the students and develop mentoring relationships. A large proportion of teaching in AAU is
carried out in Clinical Pharmacology academic time.
Within this module students spend a total of 6 days on the AAU, spread throughout the
attachment with some additional time in A&E. There is no other acute medicine exposure or
other experience of “unselected take”. Both the AAU and A&E have their own dedicated
consultant staff and a specialty triage system making it difficult for students to see the
evolution and on-going management of acute problems. Students would like more acute
medicine exposure in A&E but because of the Year 5 students they are usually asked to
leave. Some students manage to make AAU work but in general the feedback is poor;
students do not know how to cope with the lack of structure and the medical staff do not
appear to be in the position to address this due to conflicting pressures. Consultants
recognise that there is a lack of acute medicine exposure and they are planning to address
this in the coming academic year by giving students weekend AAU attachments with a rota
for supervising them.
Care of the Older Person: This is a good firm and students praised all the consultants’
(especially Dr Wagg’s) bedside and clinic teaching. It is well-organised with few cancellations
and all the timetabled teaching took place. Students appreciated having AW’s mobile
number so they have no worries about who to contact with queries. They reported that they
were not dispersed evenly into groups so they would organise a reshuffle themselves. There
is some resentment about moving between sites although the teaching facilities for COOP
are better than for some for other firms because many sessions are based at St Pancras.
Students would like more opportunities to practise procedures on this firm. AW does all the
administration himself (except for photocopying the timetables).
Rheumatology: The joint Rheumatology and Orthopaedics timetable works well at UCLH,
having a good and well balanced mix of medicine and surgery. Students give very positive
feedback about all aspects of Rheumatology teaching. Much of the teaching is provided by
academic staff and a Research Fellow contributes to the administrative work (rather than a
Trust-funded administrator). Rheumatology has been particularly adversely affected by the
closure of a ward without consideration of the impact on teaching. Furthermore there are
concerns regarding the implications of the reduced number of orthopaedic consultants on the
capacity of remaining staff to service the joint module.
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Dermatology: The UCLH Dermatology Department is currently providing approximately 50%
of all undergraduate dermatology teaching. The attachment is very busy and students spend
their time in out-patients and receive three blocks of lectures on 3 half days. Students get
good clinical exposure to general and specialist cases, however consultants teach during
clinics which have no allowance for teaching whilst having to fulfil normal service
requirements. This places them under considerable pressure. In addition the large
consulting rooms designed for teaching are not always available so the clinics can feel very
overcrowded for students, clinicians and patients.
Pathology: this was not formally included in the scope of this visit however concerns were
raised regarding the implication of changes to Dr Nandini Shetty’s contract with the Trust
which needs urgent clarification.
4. ASSESSMENT
Some consultants reported difficulties in getting to know students well enough to provide
comprehensive and fair assessments; a view mirrored by student claims that many
assessments are not credible or equitable. The fragmented Year 3 timetable and complex
firm structures contribute to this. Both students and teachers prefer groups to be attached
consistently to an individual consultant or “mentor” although some firms do manage to be
confident about their grading by seeking feedback on the students from the whole team. The
introduction of the Year 3 portfolio may facilitate this.
5. WELFARE / PASTORAL – PROCEDURES FOR STUDENTS CAUSING CONCERNS
Student attendance can be difficult to gauge in some firms due to the lack of continuity on the
firm. Clinical teachers are aware that this has welfare implications as poor attendance may
be an early indicator of a student ‘at risk’.
6. RESOURCES – TEACHING SPACE, EQUIPMENT, ETC.
Although the new building will eventually provide an excellent learning environment for
undergraduates, the Trust had made little provision for them when it moved. This has
resulted in many months of difficulties for students and their teachers, which continue even
now.
Space: Teaching space is so limited that some sessions have taken place in corridors
raising concerns regarding patient confidentiality. Block bookings a year ahead resulted in
inappropriate or sub-optimal usage of the multi-purpose seminar/meeting rooms in ward
areas. A review of the booking system should prioritise bookings for clinical teaching in
space adjacent to the wards, with committee meetings etc. moving out to Euston Rd and
other non-clinical settings. A possible benefit of the lack of space and complicated booking
system is that the amount of bedside teaching in some firms has increased.
IT & Audio visual: There are insufficient PCs in some areas and no reader access for
students to the clinical database (EPR). In order for the students to gain access they will
need to attend a data protection course (once at the beginning of each year). Clinical
teachers highlighted the lack of basic A-V equipment (e.g. PCs, projectors) and no links with
the EPR systems in most meeting rooms. These could be easily provided.
Lockers: The lockers for students’ belongings are included in the SLA but are not yet
available. The Trust’s plan was to locate all lockers in Phase 2 of the new building, due to
open in 2009. Without lockers, students have to carry all their belongings around which is
uncomfortable, raises security and infection control issues and makes them appear
unprofessional in front of patients. The Trust has given access to some lockers on all floors
but because of nurses’ early shifts, when students arrive few (none in the female areas) are
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available. The Premises Manager only recently became aware of the SLA and had submitted
a budget for lockers just before the visit. This problem requires urgent resolution.
Access: Students had no direct access to clinical areas (unless allowed in by a member of
staff) until very recently although the problem was first noted in September 05. Lack of
access significantly affected the student experience especially as it deterred them from
attending out of hours.
Library: UCLH gives £20k to the School and £15k to the library for providing access to other
UCL staff. The Team were disappointed to find that there are no library facilities on site.
7. SIFT
For historical reasons the use of, and accountability for, SIFT has not been transparent.
Following the dissolution of the SIFT Liaison Group no specific body or individual has been
responsible for SIFT monitoring within the Trust. Clinicians and students are aware that the
Trust receives a very large sum (£20m annually) notionally intended for undergraduate
teaching but find it difficult to identify its benefits. TM, who recent taken on the education
portfolio in his role as Medical Director, was confident that he would be able to deal with all
the issues raised and ensure the Trust becomes compliant with the SLA.
Consultants Teachers: Identifying the use of SIFT supporting clinical staff contracts in the
Trust is complex. Few consultants at UCLH have a PA for undergraduate teaching (as
opposed to postgraduate or MMC education), despite this being part of the SLA. However,
much of the clinical teaching is provided by UCL academics with honorary NHS consultant
contracts, who are also expected to do research as well as be service leads in many areas.
There are considerable cross-reimbursements from UCLH to UCL and vice versa. Work is
being carried out to identify, within each directorate, the distribution of PAs for teaching. It
would be helpful, in order to monitor value for money and quality, to move towards
disentangling SIFT and providing greater clarity in its use to support consultant job plans.
Liaison with the Medical School: The Visitors and the Trust recognise the need to be
mindful of the impact of service changes on students. Both parties could have ensured better
representation of the needs of undergraduates during the planning of the new building. Now
the first phase is complete, the Trust needs to consider the impact of local changes (such as
the closure of T6 on Rheumatology teaching) and ensure teaching facilities are built into
Phase 2 of the UCLH development. It was agreed that a follow-up meeting with AB or JD as
well as JMcE and TM would be essential with a view to forming a UCLH SIFT/QA Group (in
line with that at the Whittington Hospital).
8. QUALITY ASSURANCE, STAFF DEVELOPMENT AND APPRAISAL
The School recommends that the Trust ensures that monitoring and development of teaching
contribution is built in to job appraisals especially where it is explicitly included in job plans.
Relevant evidence regarding educational quality for use in appraisal is available in site visit
reports and staff / student committee minutes. In addition each module and individual firm is
evaluated through on-line forms. The School is developing Evaluation Summaries to facilitate
interpretation of the student data and to reduce the variability when student numbers are
small. The School wishes to encourage all those involved in teaching to read their on-line
student feedback on the Evaluation Website regularly.
9. SUMMARY
The Team was impressed by the commitment to teaching of the consultants at UCLH. The
new hospital provides a professional environment and the School recognises the
achievement of surviving the period of transition. However the Trust appeared to be wholly
unprepared for its ongoing commitment to students when it opened in summer 2005.
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It is easy to get the impression that the management culture of the Trust does not support its
educational obligations despite receiving over £20 million SIFT funding annually. There is no
internal transparency regarding use of SIFT. The Trust’s website claims:
"UCLH is committed to delivering top quality patient care, excellent education and
world class research."
It is perhaps symptomatic of this culture that there is no mention of medical students or
undergraduate education elsewhere on the site.
The Trust representatives we met expressed serious concerns about the current failure to
comply with the SLA and the GMC requirements, and the need to support clinicians in order
to continue to deliver high quality teaching. The School wishes to work more closely with the
Trust in the future and the appointment of Dr Jean McEwan has already had a very positive
impact on communication between the Trust and the Medical School. It was agreed that a
regular joint meeting needs to be re-established. Issues requiring action by each party are
summarised in the Action Plan, some of these have been pending for some time. The School
will liaise with the SHA if there is evidence of on-going failure to comply with the SLA.
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