Review overview

Background to the review

General surgery training at Portsmouth Hospitals University NHS Trust (PHUT) was identified as an outlier in the 2024 General Medical Council national training survey (GMC NTS). Following further feedback from the trust and a review of longitudinal data from the GMC NTS a decision was made to hold learner focus groups with the general surgery residents and foundation residents in that area to gain a greater understanding of their experience of training. This was not a full education quality intervention so did not include sessions with educators or the senior trust team.

Who we met with

• core surgical residents (7)
• higher surgical residents (12)

Evidence utilised

• GMC national training survey results
• National education and training (NETS) results

Review panel

• Education quality review lead: Mr Simon Sleight, Head of School of Surgery
• Education quality representative: Caroline Lee, Head of Education Quality
• Lay representative: Mike Wood
• Education quality representative: Sarah Lang

Executive summary

NHS England Workforce Training and Education (WT&E) South East (SE) visited Portsmouth Hospitals University NHS Trust on 13 March 2025 to undertake learner focus groups with resident doctors in general surgery. 

This followed data in the GMC NTS and the focus groups were intended to give the resident doctors an opportunity to discuss all aspects of their training experience with NHS England WT&E. Across 2 sessions we spoke to 19 resident doctors on core or higher surgical training programmes. No foundation doctors in the area attended the sessions and consideration will be given to arranging a separate focus group to hear from this group.

The panel heard concerns from core resident doctors about the culture of training and how supported they feel. Across both groups, concerns were raised about a lack of training opportunities, the culture of morning handovers, workload and staffing out of hours in 1 area and logistical issues related to parking when on call.

This report indicates several requirements for PHUT linked to the issues raised by learners.  NHS England WT&E will review whether, and if so when, to undertake a full education quality visit and discuss this with PHUT.

Requirements

Immediate mandatory requirements

No immediate mandatory requirements were identified.

Mandatory requirements

Recommendations

Review findings

Core residents (7)

The group reported that they all had trust induction. 1 resident did not have a local induction and went straight to night shifts. Many of the group reported that their ID badges did not give them access to theatres at the start and that resolution of this took weeks.

Residents reported a mixed picture around access to educational and named clinical supervisors.  Some had a good experience, and Mr Mike Glasier was commended as a particularly good educational supervisor. Others had found it very difficult to get meetings with clinical supervisors and get multiple consultant reports (MCRs) completed and 2 had been told by their allocated lead clinical supervisor for MCR to find an alternative. 

It was reported that the general surgery rota was heavily weighted to time spent on call so there was little access to what residents described as easy surgical lists. A culture of core residents being pushed out of clinical experience was described to the panel with theatres too busy for training and lots of elective lists being cancelled. Residents gave examples of a good list for training but then the registrar came in from a day off to access the list, so the core resident wasn’t able to do so. Others quoted similar experiences of higher specialty residents wanting cases which means opportunities for core residents are very limited. Concerns were raised about how a need for cases to be completed quickly means they are very consultant led, and residents do not get training opportunities. 1 anaesthetics consultant was named as being particularly difficult for residents, not wanting them to be involved in theatre and the resident group do not feel that the surgical consultants stand up for them and their training in these circumstances. The name of this individual has been provided to the Director of Medical Education at PHUT.

The negative impact of robotics on the access to training for resident doctors was raised. Training opportunities are affected in a number of different ways. Increasing use of robotic procedures is affecting training at all resident levels. Some robotic fellows were collegiate with senior residents allowing mutual progression, others less so, with fellows directly affecting access to training for some residents. The consequence of this was that higher surgical trainee residents were then accessing cases that previously would have been appropriate for core trainees.

Mr Keith Graetz and Miss Jennifer Straatman were both highlighted as consultants who provide excellent training opportunities for resident doctors and who advocate for their learning.

The morning handovers were described to the panel as toxic where everyone is on edge and there is a feeling that consultants are looking to find fault with registrars and this concern filters through the team. The residents said they always feel defensive, and the handovers do not provide learning opportunities.

The core residents told the panel about issues they have of access to car parking when they are on call; they feel pressured to leave by 9pm for the last bus and if they miss that have to wait for a taxi although this is provided by the trust.

The panel heard that the core residents do not feel able to submit exception reports.

Some instances of inappropriate behaviours by theatre staff from other professional groups towards core surgical residents were reported to the panel such as hiding gowns and pushing their hands away while retracting. The group said that some consultants did not intervene, so they did not feel part of the team. A comment was made that they always feel like a stranger to the team. As a group they were positive about the support received from the registrar cohort.

When asked about local teaching or journal clubs the group reported that there are none.

The panel asked the group whether they would recommend core surgical training at Portsmouth Hospitals. 6 stated they would not recommend it, 1 that they probably would.

Higher surgical residents (12)

The group reported a generally positive experience around induction with early meetings with supervisors and no problems with MCRs. There were some reports that badges did not give theatre access initially, but that it was resolved quickly. 

In colorectal the consultants were described as supportive and that they take training opportunities where possible. Where cases are robotic it was reported that there is no training and 45% of cases are robotic so training numbers are low especially for a high-volume department. Resident doctors work well with fellows. Colonoscopy experience was described as impossible to secure. Escalation, where needed, is well supported and consultants are approachable.

In upper GI, 80% of lists are robotic which limits training experience but residents have 1 to 2 laparoscopy lists per week that they have good access to and 1 list per fortnight for other procedures. Tension with a fellow taking cases from suitable lists was described. No endoscopy experience is available.  Miss Straatman was noted to be very good at providing training including around robotics and 1 resident reported particularly good supervision.

Some handovers were reported to be a hostile environment with registrars not feeling supported and some have seen and been subjected to undermining. Some individual consultants were named as being more of a concern around this.

There was a view expressed by the group that they miss out on training opportunities because of a surgical first assistant (SFA) who, they believe, gets preferential access to training and operating lists and an example was given of residents being stood down from cases very late to allow the SFA to be present.

Out of hours there were concerns raised about workload and lack of staffing. Overnight there is 1 foundation year 1, a core surgical resident and a registrar, the foundation doctor has to accompany patients to CT overnight which often leaves 2 residents covering 120 patients across 4 wards.

The group told the panel that handover can be brutal, with significant criticism for small things.  Anxiety about the morning handover was described to the panel. Residents told us this causes a reluctance to message consultants about patients.

The panel heard positive feedback about the experience in transplant where there are still non-robotic general surgical lists where residents can get good experience.  However, concerns were raised about staffing levels with no SHOs or foundation doctors although there is a physician associate who is very good. 

There was excellent feedback on the experience in breast surgery with supportive consultants although the on-call commitment is 50% of time.

Across the group Mr Keith Graetz and Mr Nick Carter were praised for their support for training and operating including overnight.

This group of residents felt unable to submit exception reports some for fear of a backlash and others because they feel it is a waste of time.

They raised the same concerns about car parking whilst on-call as the core surgical residents.  The residents reported that they do not have local teaching. 

The panel asked the group whether they would recommend higher surgical training at Portsmouth Hospitals. 1 of the 12 would recommend the post.  None would recommend it for a consultant post. 

Report approval

Report completed by: Caroline Lee, Head of Education Quality

Review Lead: Mr Simon Sleight, Head of School of Surgery
Date signed: 3 April 2025

NHS England authorised signature: Dr Paul Sadler, Regional Postgraduate Dean
Date authorised: 6 May 2025

Final report submitted to organisation: 6 May 2025