Executive summary

The primary purpose of the Monitoring the Learning Environment (MLE) meeting was to review the Intensive Support Framework (ISF) open requirements in Medicine. The meeting was triggered in response to poor General Medical Council (GMC) National training Survey (NTS) data.

• There was a marked global decline in the GMC NTS 2024 scores and the trust were surprised and disappointed in the results.
• The trust has made some progress with the ISF open requirements in Medicine (see page 6).
• There are staffing, leadership, engagement and culture issues in Medicine and help is needed from the trust senior leadership team and NHS England.
• The trust has expanded the Foundation Year 1 and 2 rotas, which has helped with staffing levels.
• The trust highlighted areas that are working well including Respiratory Medicine, Paediatrics, and the Emergency Department (see page 9).
• NHS England will follow-up areas of concern in Anaesthetics and Obstetrics and Gynaecology (O&G) with the Heads of School with the possibility of opening speciality concerns.
• The Medicine ISF1 requirements are to remain open apart from the supervision requirement, which is resolved and will be closed.
• If satisfactory engagement from the medical leaders and progress is not made, then consideration will be given to progressing the ISF to level 2.
• The date of the next Senior Leader Engagement (SLE) visit is September 2025.

Review overview

Background to the review

MLE meetings are undertaken to ensure that quality risks are managed effectively, and notable/good practice is identified and shared across the region, building on, and strengthening relationships with the organisation.

Evidence:

• 2024 Trust Self-Assessment (SA)
• 2024 Trust All Open Requirements Report
• 2024 NHS England Quality Interventions Report
• 2023 National Education and Training Survey (NETS) Highlights
• 2024 GMC NTS Multiple Outlier Report
• 2024 GMC NTS Scores and Ranking Reports
• 2024 GMC NTS Programme Group Data
• 2024 GMC NTS Bullying and Undermining Comments
• 2024 Guardian of Safe Working Hours (GOSWH) Report – February to April

Who we met with

Education team:

• Clinical Director Acute Assessment Unit (AAU)
• Education Fellow
• General Manager Medical Directorate Unit
• Director of Medical Education
• Guardian of Safe Working Hours
• College Tutor for Medicine

Review panel

• Education Quality Review Lead, Adam Burns, Associate Dean
• Education Quality Review Lead (Shadowing), Muzzammil Nusrath, Associate Dean
• Quality Lead, Joanne Seddon, Quality Support Manager
• Administration, Michele Hannon, Quality Administrator

Review findings

Trust update

• The trust was disappointed and surprised by the poor GMC NTS scores as there had been an upward trend in the last three to four years and acknowledged that they had work to do to understand and address the results.
• There was no suggestion from the Postgraduate Doctors in Training (PDiT) forum that the data would be so poor.
• There remains Exception Reporting (ER) regarding missed educational opportunities. However, in contrast to GMC NTS, NETS data had been stable.
• There has been good work from the Chief Registrar (CR) and the Clinical Skills Fellows who have been working with PDiT and vulnerable doctors and it was advised that there had been moderate improvements in staffing.
• The College Tutor (CT) for Medicine advised that the trust was ahead of the curve in Self-Development Time (SDT) and any dissatisfaction has been addressed but some of the work for the ISF’s was too late to be factored in for this year’s GMC NTS.
• There are several areas that are working well including Respiratory Medicine, Foundation Year 1 (FY1), Paediatrics and Emergency Medicine (EM). See page 9.
• Overall, the trust scores map the national mean scores but are just marginally worse in most areas and if the overall satisfaction could be improved this would help, but the trust recognise this will be a challenge.
• There were low levels of respondents in Surgery Foundation Year 2 (FY2) with an overall satisfaction score of 18% and the trust stated this was unusual and they were not aware of this level of dissatisfaction.
• Medicine scores are poor, and the opinion of postgraduate education is that this has been affected by staffing, leadership, and how PDiT are managed and moved daily without access to senior support.
• The trust reported that FY2 in Medicine is poor compared to other trusts and acknowledge that this is a real issue, and that further work is needed to improve the situation.
• Surgery is in the lowest decile for Foundation Year (FY) with PDiT concerns about supervision and support when consultants are out of the hospital. The trust believes this relates to PDiT in Trauma and Orthopaedics (T&O) with limited access to Orthogeriatrician support.
• The trust has arranged meetings with the FY2’s and the first meeting took place last week, but no PDiT attended.
• The O&G and anaesthetics data is very poor and was a surprise to the consultants who responded that PDiT return to be consultants, and locums (employed due to high levels of sickness) send positive feedback letters. The O&G tutor felt that improvements had been made at the time of the survey. The trust is working with the Anaesthetics department regarding the negative feedback.
• The trust advised there had been an accusation of incivility and unsafe areas of work and acknowledged the challenges that they face in changing behaviours and making improvements.
• The Medical Director (MD) and Deputy Medical Director (DMD) have stepped down and relationship building will be needed with the new team.
• The trust’s poor financial position impacts on staffing. Not all the money is accounted for, and the education team is working on identifying funding streams so hopefully there will be spare funds.
• There are leadership structure challenges, particularly in Medicine, and finding the right person to decide on key issues is extremely difficult.
• Staffing remains an area of concern; delivering a service that is not reliant on locums and regular ward swaps is challenging.
• Supervision across several specialities and access to a named supervisor is the same model as ten years ago. There is one medical registrar and one on-call in Trauma and Orthopaedics (T&O) and PDiT are unable to get help when needed.
• The education team report to the Board. However, they have had not heard back from the trust board regarding support with Medicine and the middle tier, financial transparency, additional funding for education leadership in Surgery and an appointment for Locally Employed Doctors (LED) for which they put in a funding bid and would welcome NHS England’s support.

GOSWH update

• PDiT engagement is poor, and work is needed to raise the profile and other GOSWH have been approached to learn how to encourage attendance.
• There has been a lot of change in the last three months including a third person in Surgery at weekends to support the Foundation rota and the increased number on weekend out of hours between 8pm and 2am has meant reduced ERs.
• The Medicine FY1 rota has improved from 1:14 to 1:16 and the FY2 from 1:7 to 1:10 and rota gaps have been reduced as several LEDs have been employed.
• There has been feedback regarding clinical oversight in the Medicine rotas as there are lots of Less Than Full Time (LTFT), which can be felt by PDiT on the ward, so some work is needed. Lack of clinical oversight of medical rotas remains a concern.
• Feedback has been given to the trust about gap reductions. Over recruiting comes at a financial risk, but it increases rota stability in cases of unplanned absence.
• The trust confirmed there is one extra person on the Respiratory rota, but overall, the numbers on the on-call rota have not changed and there are a still several gaps.
• NHS England queried if the trust had taken up FY1 and FY2 expansion.
• The trust confirmed that they had but they must balance the quality of supervision and skill mix against the amount of senior support available, so they were cautious with numbers taken.
• The trust added that there is an expansion post for Acute Internal Medicine (AIM) as they are the only trust with a single registrar so this will double up numbers on the rota, but not until August 2025.
• The current cohort are not engaging with the trust, but they are engaging with the GMC NTS, and this needs to be investigated. The Resident Doctor Forum (RDF) was cancelled in July as there was only one PDiT in attendance.
• ER declined and there was a general feeling that nothing is working and that PDiT were possibly disengaged and angry.
• Since August there has been 71 ERs relating to working patterns and hours and this has increased in recent weeks, which suggests improved PDiT engagement with the exception reporting process.

Open Requirements (ISFs) in Medicine

Trust actions

• The trust delivered a presentation on the progress on the ISF1 open requirements and agreed to share this with NHS England.
• The trust is liaising with other trusts to see if they can share good practice to address the ISF’s in Medicine.
• Staffing levels: the trust has expanded the FY1 and FY2 rotas.
• There were some gaps on the on-call, but these have been fully recruited to but are not yet in post.
• They are in a better position than last year as numbers have expanded slightly but not enough.
• Two diary exercises were carried out including workload, place of work/ward moves and there was a 50% response rate.
• The majority of PDiT said that the intensity is acceptable, but they are struggling with a heavy out of hours workload and they are working longer hours.
• The trust is encouraging ER with the aim of getting a second on-call Medical Registrar and are hopeful that this increase will help with the number of days PDiT are off base wards.
• Data from the rota team highlights that the ward moves by Foundation Year 3 (FY3) trust grade is not reflected in the survey.
• Some ward moves to cover last minute sickness are unavoidable but in the last few weeks there have been changes to ensure the doctor working the long day will remain on the base ward during the day.
• There are departmental teaching sessions, and PDiT are encouraged to attend but they are struggling to get off wards and they are fearful of getting off the ward late.
• The second medical on-call should result in increased educational opportunities.
• All PDiT have a Clinical Supervisor (CS) from the speciality in which they are training and are getting good quality supervision which can be accessed formally or informally.
• The CT conducted a survey to look at perceived support which highlighted a few key findings, and actions were taken including a new escalation policy, which is covered at induction along with emotional and pastoral support.
• Concerns in the Haematology and Oncology Day Unit (HODU) were escalated. Medicine has a lot of work undertaken by locums who do not supervise PDiT.
• The trust is currently undertaking a project on supervision and support out of hours to gain a second registrar and CT level for overnight on the AAU.
• All PDiTs have a CS in the specialty they are working in and can access supervision.
• Protected time has improved and the majority of PDiT have been able to take study leave. However, there are issues with attending departmental training.
• There has been a problem with PDiT getting to mandatory training, prticularly FY1s, but this is being addressed with the Training Programme Director (TPD) who has emailed the doctors on the ward to say they must be released.
• Minimum staff numbers need to be looked at in Elderly Care.
• CS/Educational Supervision (ES) has improved but the challenge is not purely access to a supervisor, but out of hours overall so looking at a second registrar in Surgery will help.
• Resident doctors in T&O report difficulties in accessing support for complex medical issues OOHs. This may be improved should the trust secure a second medical registrar.
• The trust has received reports suggesting a culture which is not supportive of education and training in the Anaesthetic and O&G departments.
• There is a growing degree of apathy with Foundation trainees which stems from a lack of trust, with frequent ward movements, improvement of e-Patient record being pushed back, and goal posts being moved from one week to the next.
• NHS England stated that Foundation Surgery is the first group to look at.
• NHS England queried if the MD and DMD appointments had been made and asked what support NHS England could offer the Board.
• The trust advised that they had not met the new Board appointees yet but once in post they will brief them and assess what kind of leadership they will provide. An interim MD had been appointed from 11 December 2024 subject to confirmation.
• The DMD vacancy is going to advert and 4 x Programmed Activities (PAs) a week will be Tom Hollins. POST-MEETING NOTE: The composition of the DMD and Divisional Director posts has altered slightly. Tom Hollins will be remaining in a DMD post, increasing to 5 PAs. A further 5 PAs has been advertised and appointed to. Whilst the full portfolio of DMD responsibilities has yet to be allocated, Tom Hollins will continue supporting the workstreams. Sal Uka has arrived as the interim Medical Director (11^th December, for 6 months).
• The Divisional Director post has been advertised and there has been some interest, all are well known to the trust, and some were in interim posts and are aware this is high on the list of priorities.
• NHS England added that the emerging areas of concern in Anaesthetics will need investigating.
• The trust advised that they had not noticed the request for the GMC NTS priority list triple reds for FY2s, but this leads into the engagement work being undertaken and will respond to NHS England in 2 weeks.
• NHS England added that a lot of work is ongoing with the ISFs, and they have achieved areas around supervision and rotations using recruitment, but work is needed in CS in Medicine out of hours.
• The trust felt that this was a fair summary, but they have made some progress with out of hours in Medicine as having an extra medical registrar will have a huge impact across Medicine and Surgery.
• The postgraduate education team have highlighted that they remain concerned about the lack of engagement from the medical leadership team.
• The Education team still feel there are challenges with building a culture of strong educational governance and support within the trust, and need senior team buy-in to resolve this, but it has been a challenge with a lack of attendance at meetings particularly at divisional level in Medicine around workload and capacity.
• The trust has secured funding for a workforce lead in Medicine.
• NHS England added that the open requirement needs to remain at ISF1 but if it is escalated this would be added to the national risk register.
• NHS England commended the trust on their proactive approach and progress made in addressing the issues, and for the helpful presentation which provides robust evidence for the Medicine ISF open requirements.
• NHS England outlined that the GMC NTS bullying and undermining (B&U) comments were to be monitored locally and queried if there was any further feedback about Urology.
• The trust advised that the PDiT had been moved to another trust and an independent investigation was launched, but not upheld and there is ongoing work to understand if there are further concerns.
• NHS England asked for an update on the trainer involved and whether they should continue with their trainer status.
• NHS England to review the trust progress update for the Medicine open requirements and will require further updates on the ISFs in six months’ time.
• NHS England confirmed that discussions will take place with the Heads of Schools in O&G, Anaesthetics and Foundation to see if speciality concerns are needed.

Actions

• Medicine ISF open requirements to remain open at ISF1 apart from the open requirement for CS/ES, which is resolved and can be closed.
• The Quality team to review the information provided by the trust and revise the ISFs if necessary and respond to the trust.
• Trust to provide triple red outlier actions in the next two weeks.
• Trust to provide an update on the GMC B&U Urology comment and trainer status.
• Trust to provide an update on the Medicine ISF open requirements in six months’ time.
• Adam Burns to speak to Heads of Schools regarding the areas of concern for Anaesthetics and O&G with the possibility of opening speciality concerns. 

Areas that are working well

• The Department of Respiratory Medicine is a success story, which is reassuring.
• FY1s are doing very well and are on an upward trend and the new FY1 TPD is doing good engagement work which is reflected in the feedback.
• Paediatrics have strong feedback.
• The EM department continue to be the go-to for placements and they have high calibre candidates which will help the experience of PDiT.
• They are growing the trainer workforce, with the DME delivering the training.
• The Postgraduate Education Group had an annual away day for the senior educational workforce and looked at the education of Gen Z and the changing needs, and trainer scores are going from strength to strength.

Report approval

Report completed by: Joanne Seddon, Quality Support Manager
Review lead: Adam Burns, Quality Associate Dean
Date approved by review lead: 16 December 2024

NHS England authorised signature: Jon Hossain, Deputy Postgraduate Dean
Date authorised: 18 December 2024

Final report submitted to organisation: 22 January 2025

Publication reference: PRN01548