Executive summary

We believe that Wirral University Teaching Hospital NHS Foundation Trust has some fantastic learning opportunities for the doctors in training who come here. In our previous visit we found that issues with the rota prevented doctors from accessing them in some cases.

We are able to report progress in several areas which support linking doctors in training with the educational opportunities.

The trust has engaged in strategic succession planning and we have de-escalated previously held risks around educational governance. There is still some way to go in decentralising some functions, but responsibility for rotas appeared to have been devolved to divisions in most cases. We did find example of single points of failure and a lack of resilience to short-term workforce shocks.

We received a written action plan immediately following the visit, demonstrating the education team’s commitment to improving the working lives of doctors in training. We will keep engaging with the team outside formal visits for updates as the action plan progresses, and revise our intelligence as newer data is made available.

Review overview

Background to the review

We carried out a Learner/Educator Review at this trust on 11 June 2024, meeting with doctors in emergency medicine, obstetrics and gynaecology, and cardiology training posts, as well as their educators. While this Senior Leadership Engagement was planned as a direct follow-up meeting to discuss the leadership team’s response to the June intervention, the original date of this meeting had to be postponed and there came to be a long delay between the visit and the follow up meeting. During this intervening period, the trust had made significant progress on the actions and recommendations highlighted in the Learner/Educator Review report, and had also experienced new challenges that needing addressing. The trust declared a critical incident on four separate occasions between October 2024 and January 2025, indicating some of the pressures faced by the team. We also followed up on new concerns around foundation doctors and surgery that had been brought to our attention in recent months.

Who we met with

Education team

• Deputy Medical Director
• Director of Medical Education
• Deputy Director of Medical Education
• Lead for Medical Education and Workforce Transformation

Review panel

• Simon Carley, Associate Dean for Quality
• Gurinder Tack, Associate Dean for the trust
• Zander Zambas, Education Quality Manager
• Leanne Moore, Education Quality Coordinator

Review findings

We asked specifically about each of the Areas for Improvement identified in the report following the June 2024 Learner/Educator Review. We received a verbal update in each area during this Senior Leadership Engagement, and the trust shared their action plan to meet the requirements of the report immediately following the meeting.

Our first requirement related to clinical input and departmental oversight of rotas, and we heard a great deal about the obstetrics and gynaecology division and rota specifically which had faced the challenge of an extended period of absence from the college tutor. Notwithstanding the difficulties of covering such a key role in the department, we noted the risk of single points of failure and the need for resilience in the governance of any division.

We heard an update on the trust’s progress towards self-rostering. This was said to be in effect in medicine and emergency medicine, and that obstetrics and gynaecology were moving in that direction. The implementation was rudimentary at this early stage, with simple spreadsheets being coordinated by clinicians prior to sending on to medical staffing. However, the trust was looking to the Integrated Care Board to procure a more comprehensive e-rostering solution.

Another requirement related to developing a trust-wide workforce strategy which would support divisions to creatively address workforce shortages. We heard several examples of workforce shortages, including gaps sent from the North West and Welsh deaneries, maternity leave, long-term absence of staff due to sickness or otherwise etc. We understood the leadership team were supporting divisions with these kinds of issues on a case-by-case basis.

We were pleased to see a proactive approach to succession planning at the trust in light of the expected retirement of the incumbent Director of Medical Education. A particular area of concern is replacing both educational and workforce knowledge and skills; while any successor will be expected to have a background in education, it is more likely that workforce knowledge will be harder to come by. The Deputy Medical Director was looking at models and mechanisms to achieve this combination of workforce and educational expertise in future iterations in the team, and was keen to accept support with the governance of education and workforce, and panel members signposted to another trust which had embedded this within their processes and offered to broker a learning opportunity.

Exception reporting was being embedded within induction processes, with an educational video shown at induction and working towards processes which ensure new doctors have access to the exception reporting system as they start.

A requirement we had included in the last report stipulated that regional teaching should be rostered on for all doctors. The trust were quite confident that the disparity of experience between doctors in different teams, specialty training pathways and grades had been resolved.

The education team was able to provide a reassuring update on cardiology and clear measures of progress that had been achieved in recent months, notably the appointment of a Trust Specialty Training Lead who was working towards delivering a local cardiology induction, and bolstering the staffing numbers from two to three on the rota.

The trust also provided an update on cultural work in cardiology in response to some feedback from doctors in cardiology training documented in our report. There was a programme of work to raise the level of communication skills and improve the bedside manner in certain individuals and as a whole department.

Concerns about a negative culture had been raised with us about the experience of fifth year undergraduate medical students in surgery at Arrowe Park. While our responsibility extends only to postgraduate medical education, we anticipated that a negative learning environment for fifth year medical students may be shared by foundation doctors. We followed up by speaking with foundation doctors and corroborated some of the cultural concerns and picked up some safety issues as well. We shared these with the trust during the Senior Leadership Engagement, but will outline the key points here as well:

• There were examples of lone care provided by foundation year one doctors, where these foundation doctors are the only medical review of patients, sometimes for several days.
• On call shifts for the foundation year two doctors were concerning. They told us they share a rota with doctors in speciality training and are exposed to expectations above their competence. Out of hours is described as very busy, and they claim to have had no effective induction for this role which includes cover for ENT (ear, nose and throat), for example complex airway procedures, nasal packing for haemorrhage.

The trust had taken a robust approach to handling the concerns of the undergraduates, which had been raised directly with the trust by the Medical School at the Higher Education Institution. We were satisfied that these concerns had been taken seriously, investigated and thorough answered. As well as a verbal update with a strong grasp of the details of these concerns and appropriate mitigations, we have also had sight of numerous supporting documents which evidence ongoing engagement with the undergraduate students.

The concern about foundation year two doctors working outside their competence was a new one, and the medical education team agreed to take this up and investigate.

We learned of an internal culture review which was carried out in the surgery department in October 2023, with concerning findings. An action plan was produced and we were told of an initial flurry of activity, which had unfortunately not been sustained due to workplace pressures and external factors (for example activities which were cancelled due to the October 2024 cyber attack on the hospital trust). It was encouraging to hear that this work was being picked back up and that the GMC were linked in with regular meetings in this space, we were grateful for the offer of also being included in update in the actions following this review.

Given the timing of this engagement event at the end of February, we were looking forward to the imminent release of data from the National Education and Training Survey 2024 and shortly afterwards the opening of the GMC National Training Survey. We discussed the trust’s plans to follow up on the survey results, increase uptake of the survey submissions and the team’s expectations of where there may be challenging results and negative outliers.

Areas that are working well

• Succession planning is being considered at a strategic level, and we are able to observe a more resilient distribution of responsibilities than previously among the medical education and leadership team.
• Cardiology was described as a fragile service during our summer visit, and developing resilience and capacity in the division was a key aim. With an important appointment to TSTL (Trust Specialty Training Lead) and a portfolio of activity lined up, including an induction for the next rotation of doctors, this is a much improved situation.

Good practice

• The trust clearly had responsive processes to manage the reported poor experience of undergraduate students on placement in the hospital.

Areas for improvement

Mandatory requirements

In addition to ongoing items on the existing action plan.

Report approval

Report completed by: Zander Zambas, Quality Support Manager
Review lead: Gurinder Tack, Associate Dean
Date approved by review lead: 27 March 2025

NHS England authorised signature: Simon Carley, Associate Dean for Quality
Date authorised: 26 March 2025

Final report submitted to organisation: 2 April 2025