Executive summary

We conducted a Learner/Educator Review at Alder Hey Children’s Hospital on 17 June 2025. The review found a mixed picture: while many areas demonstrated strong educational practice, others raised serious concerns. The intensive care unit stood out as a model of good practice, with structured induction, consistent consultant presence, and the innovative “chief week” model offering meaningful leadership experience, putting to rest some previously held concerns about the quality of training on the paediatric intensive care unit (PICU). Subspecialty training was generally well supported, with curriculum mapping and proactive supervision in many departments. Educators across the trust were engaged and committed, and the introduction of self-rostering was widely welcomed for improving work-life balance.

However, general paediatrics and the on-call rota emerged as a significant area of concern. Trainees reported inadequate induction, inconsistent supervision out of hours, and a lack of structured feedback. Staffing shortages and rota gaps were seen by some of the resident doctors interviewed to compromise educational quality. Some resident doctors reported feeling unsafe in community placements due to historical issues with lone working and unclear escalation pathways. Across the board, feedback and assessment practices were variable, and many doctors struggled to document their learning effectively. Physical infrastructure, including rest facilities and administrative support, was also found wanting.

The trust was immediately alerted to a patient safety risk relating to out-of-hours supervision in general paediatrics, and a satisfactory response has since been received. Further actions include reviewing consultant staffing in general paediatrics, improving induction processes, standardising handover practices, and addressing lone working risks in community settings.

The findings of this review will be shared with the trust’s education leadership team and relevant clinical departments. An action plan will be developed in collaboration with stakeholders, focusing on the identified areas for improvement. Progress will be monitored through regular engagement to assess the impact of implemented changes, but no further formal quality interventions are scheduled at this stage, underlining the confidence of the panel in the trust’s governance processes in resolving concerns of the nature identified in this report.

Review overview

Background to the review

The reason for planning this intervention was mainly due to the results for several subspecialty training posts at Alder Hey which scored very poor results in the GMC National Training Survey in 2024, so much so that the trust appeared five times for different subspecialties on the GMC’s own priority list of concerns from that time. The programme view for paediatrics also had numerous outliers. Through discussions with the trust’s education team, we took a view that we should speak with doctors in general paediatric training as well as doctors in paediatric subspecialty training. Our concerns about the intensive care unit have been ongoing intermittently for three years and have been discussed with the trust on numerous occasions during that time. This visit presented an opportunity to speak directly with the doctors working on the paediatric intensive care unit. The results from the 2025 National Training Survey were not available to the trust nor the panel at the time of the intervention.

Who we met with

Learners

• 8 × doctors in general paediatric training posts
• 9 × doctors in GRID (subspecialty) training
• 3 × doctors in paediatric intensive care training

Educators

• 8 × consultants in general paediatrics
• 11 × consultants in subspecialties with supervisory responsibilities for GRID doctors

Review panel

• Simon Carley, Associate Dean (Education Quality Review Lead)
• Gurinder Tack, Associate Dean
• Guy Makin, Head of the School of Paediatrics
• Helen Duff, Education Quality Senior Manager
• Zander Zambas, Education Quality Support Manager
• Leanne Moore, Education Quality Coordinator
• Carole Aitken, Education Quality Coordinator
• Sue Barker, Lay Representative

Review findings

General paediatrics

We heard consistently from doctors in general paediatric training that the local induction process was inadequate and left many feeling unprepared for their roles. It was described as the “worst induction” experience some had encountered, with a strong assumption that all attendees were already familiar with Alder Hey’s systems and culture, the ‘Alder Hey way’. It was reported that the induction lacked basic orientation to the hospital, and that the handbook provided was significantly out of date. It was described as potentially a satisfactory induction geared towards internal rotations, but left those joining Alder Hey for the first time lost and confused. This experience was starkly contrasted with the corporate induction, which was more structured and effectively delivered on practical elements such as ID badge distribution. Several doctors pointed out the additional stress of car parking.

We were pleased to hear that a self-rostering system was now live for this rotation. We heard that self-rostering had improved work-life balance and allowed for greater flexibility, particularly in accommodating personal events. Doctors were overwhelmingly positive about the change. However, there appeared to be some minor errors and mishaps through the roll out which we are sure the trust will iron out in due course. These include the delay in issuing the rota, though the cohort we spoke to were very understanding of this. There was also concern about errors or lack of tactical oversight of the middle grade rota, leading to situations such as four doctors in respiratory training scheduled at the same time. The senior rota for registrars was viewed more favourably overall, though doctors with special interests (SPIN) found their SPIN training time to conflict with the self-rostering system.

We heard that there is good consultant support for the take, but the “fragmented cover” at other times was the cause of great distress, including out of hours. We were told that foundation doctors (in first and second years) found it difficult to escalate concerns and could feel unsupported.

We asked about handover processes and whether they presented educational opportunities, and we were told of vastly different and non-standardised arrangements that “depends on the individual consultant”. Some consultants would ask the resident doctor to present patients, or just report the new admissions, others would do the ward round together with the resident doctors, with several other models of handover described. Certain times were understood to be less effective as learning opportunities, for example the 8am handover with the post take consultant falls at the end of the night shift and there was little appetite for loading these with educational content, but many doctors identified missed opportunities for learning and feedback.

Feedback and supervision were also highlighted as areas of concern. We were told that feedback was rarely given directly and that a culture of “no news is good news” prevailed. While educational supervisors were generally described as supportive and knowledgeable about the curriculum, there were challenges in using the e-portfolio system, and doctors in training often had to be proactive in chasing assessments and workplace-based feedback. The perception was that doctors in subspecialty training were more likely to receive consistent feedback due to greater continuity with consultants, whereas those in general paediatrics often lacked this continuity.

We were told that completing curriculum requirements, particularly for the annual review of competency progression (ARCP), became increasingly difficult at senior levels. Opportunities for teaching were generally good, with a growing simulation programme in general paediatrics, although attendance at grand rounds was limited. The quality of teaching varied between specialties, and some doctors noted that simulation sessions had been disrupted due to staff absence.

In terms of equality, diversity and inclusion (EDI), little specific training was reported beyond the basic level of mandatory training. One doctor in training told us their supervisor was the ‘EDI lead’, which allowed them to be heavily involved in promoting EDI in the workplace, and there was high praise across the board for some initiatives such as the “interpreter on wheels” which was effective in bridging language barriers.

Generally, the doctors we spoke to believed that they were treated with respect, and that patients were treated with respect. They were confident in speaking up about issues if this were not the case. The only dissenting voice to this consensus was a story about a patient’s family treating the resident doctor ‘horribly’ and precipitated a ‘near-physical confrontation’. The resident doctor did then raise this and try to escalate the incident; they felt listened to, but that the organisation’s response was insufficient.

While this cohort felt comfortable raising concerns, they did observe issues with the practical business of incident reporting. We heard that resident doctors had to ask for access to the incident reporting system. Some told us of submitting (possibly historical) incidents on someone else’s account. Nurses were seen to champion the incident reporting process, possibly to the detriment of doctors’ involvement. Feedback from submitted incidents was not expected based on their previous experience.

Despite these challenges, the doctors spoke positively about their working relationships and the support they received from peers. Study leave, audit opportunities, and access to library resources were all reported as being available and supported. Most doctors said they would recommend the placement, though several suggested that improvements to supervision, handover processes, and the doctors’ mess would enhance their experience.

PICU

The small group of doctors we spoke to working on the Paediatric Intensive Care Unit (PICU) were highly positive about their experience on the unit, with its emphasis on support and education in a cohesive team culture.

The corporate induction received similar praise as we had heard before, and the local PICU induction was held to a similar high standard. Two days were focused specifically on PICU, during which time, new inductees were able to shadow colleagues and spend meaningful time on the unit, which helped to ease the transition into what many acknowledged could be a daunting clinical environment. There was a clear recognition from the team that new starters may feel nervous, and the induction was structured to address this with sensitivity and clarity.

The rota was described as flexible and well-managed. Although not self-rostering, it was coordinated by a single individual who was responsive to requests for annual leave and specific weekends off. We were told that the rota was released on time and that it accommodated personal needs effectively. Consultant presence was consistent, including overnight, and supervision was described as excellent. Doctors at different grades felt empowered to take on responsibilities and reported that support was always available when needed.

A distinctive feature of the PICU placement was the “chief week” model, in which doctors in higher subspecialty training or senior training grade clinical fellows were able to shadow consultants and effectively stepped into a consultant role under supervision. This was seen as a valuable educational experience that also created space for more junior members of the medical team to receive additional teaching. We were told that this model had a positive knock-on effect across the team, enhancing both learning and service delivery.

Workplace-based assessments (WPBAs) were generally able to be completed, although it was understandable that consultants and supervisors had to be prompted to sign-off on them. This was not seen as a major barrier, and everyone present expressed confidence that their assessments would be completed in time for their annual review of competency progression (ARCP). Case-based discussions (CBDs) proved to be the most challenging to conduct, though this was attributed more to timing than to a lack of opportunity. It was reported by several doctors that the rich learning environment in PICU was not fully reflected in their portfolios.

Handover was described as well-structured and educational, particularly in the mornings. The 8:30am handover involved the full team and was seen as a valuable learning opportunity. The evening handover was slimmer but still effective. We were told that handover practices had improved significantly over the past year and that consultant presence contributed to a culture of safety and learning. Feedback was described as consistent, particularly during “chief weeks”, and educational supervisors were viewed as approachable and supportive. While some supervisors were not fully familiar with the e-portfolio system, it was noted that any issues were quickly resolved once discussed.

Formal teaching was described as frequent and high quality, with learning opportunities available on most days. Monthly teaching days were in place, and simulation training was offered on an ad hoc basis during these sessions. While some doctors were unable to attend external teaching due to scheduling conflicts with handover, teaching sessions were often recorded, and time off in lieu was provided when training was attended on days off. Study leave was well managed and pre-allocated on the rota.

We elicited no concerns regarding equality, diversity and inclusion. The use of a video-based language line was again singled out for praise, and the unit was described as respectful and inclusive. No instances of bullying or undermining were reported. Incident reporting was well understood, and everyone felt confident in using the system. They also reported feeling listened to and included in discussions, with a clear sense that their contributions were valued.

The unit’s relationship with the wider hospital was described as ‘functional’, though it was noted that PICU operated somewhat independently. Patients typically arrived via anaesthetics or the transport team, and there was limited need for doctors on PICU to attend other wards. Communication with specialty teams, including cardiology and cardiac surgery, was generally effective, though some strained relationships were acknowledged. These were not seen as barriers to patient care.

We had come to speak with doctors in paediatric intensive care due to a history of poor results in the National Training Survey and triangulating intelligence about concerns on PICU. We could not recognise any of these concerns while speaking to the doctors currently working on the unit, and so we asked if they were able to explain the discrepancy between historical intelligence and current experience. Several recent improvements were repeated, such as handover practices, but more fundamentally the doctors reflected on the job itself not being a good fit for everyone. The example of doctors in higher specialty (adult) intensive care medicine or anaesthetic training nearing their certificate of completion of training (CCT) and working at a consultant level could feel under-skilled in the very different PICU environment. This speaks to the broader structure of postgraduate medical training rather than to any local issues, though it was suggested that the induction could be adapted to better support these individuals. The unit was clearly a very effective and well-run unit for those who were committed to being there, and the only minor improvement suggested was to achieve timely completion of assessment documentation by supervising consultants.

GRID training (paediatric subspecialty training)

Doctors in paediatric subspecialty training pathways (also known as GRID training) shared a complex and often polarised view of their experience at Alder Hey. While many described high-quality clinical learning and supportive supervision within their specialties, there were also significant concerns about the structure of training, the balance between service provision and education, and the safety and culture of the general paediatrics and community placements.

Concerns about general paediatrics were a recurring theme. GRID doctors described a culture in which general paediatric consultants were reluctant to provide support, particularly out of hours. Several reported incidents in which consultants refused to attend when requested, even in serious clinical situations. One doctor described being openly bullied in front of colleagues and receiving no support when the issue was raised with a supervisor. Another recounted a case involving a child protection concern where they felt unprepared and unsupported, having not received the necessary out-of-hours training. These experiences contributed to a concern with general paediatric service delivery, and several doctors stated that they would not return to the general rota under any circumstances.

Induction was described as standardised but impersonal, and that it assumed prior familiarity with the hospital, with no tour of the building and limited tailoring to one’s specific roles. One doctor observed that they had a great deal of mandatory training to complete, and the time allocated to do this fell well short of the time required. Others described the specialty induction as intense and overwhelming, with a large volume of information delivered over three days and no scheduled breaks. Shadowing opportunities following induction were appreciated. Doctors who started their rotation out of sync with the main cohort reported feeling under-informed and unsupported. In some cases, they were left to organise their own outpatient experiences or attend clinics without appropriate preparation or supervision.

Work schedules were often issued late or contained errors, though rota coordinators were described as helpful and responsive. In several cases, the department was aware of an individual doctor’s arrival, but this information had not been communicated to the wider trust. Self-rostering was in place for the medical on call rota, and emergency medicine was transitioning to this model. Where bespoke rotas were used, the flexibility to request specific shifts or leave was appreciated. However, many GRID doctors reported that rotas were felt to be primarily built around service provision, with limited consideration for individual and subspecialty specific training needs (despite the allocation of Continuing Professional Development [CPD] time and administrative time).

Curriculum coverage was a major concern, particularly in community paediatrics. Doctors in community paediatric training reported that they had little or no access to essential areas such as fostering, adoption, ADHD, and neurodisability. One such doctor was told to use study leave to shadow clinics in order to meet curriculum requirements, which they felt was not equivalent to structured training. Others described being assigned to school-based clinics without a chaperone, induction, or risk assessment. These experiences raised serious concerns about lone working, personal safety, and the lack of organisational oversight. Some doctors in this situation reported feeling unsafe and unsupported, with no clear escalation pathways or communication between Alder Hey and external providers such as Mersey Care.

Much like we heard in intensive care medicine, a disconnect was described between the learning they were doing and what was captured in their portfolios. Many reported that they were learning a great deal on the job, but that time pressures, lack of administrative support, and difficulty obtaining sign-off for supervised learning events (SLEs) meant that their progress was not adequately documented. Some had resorted to using reflective logs in place of formal assessments. Feedback was described as variable: some specialties, such as gastroenterology and infectious diseases, provided regular and constructive feedback, while others, particularly community paediatrics, offered little to none. One doctor remarked that they had never received feedback in community placements and assumed they were doing well simply because no one had said otherwise. The “chief week” model was again praised for providing meaningful feedback and leadership experience.

The physical working environment was also offered as an area in need of improvement. We were told of a lack of dedicated office space, no access to phones, and inadequate rest facilities. Resident doctors told us that administrative time was insufficient, and doctors often completed reports and portfolio work in their own time. Some expressed concern that they were not being adequately prepared for independent practice, particularly in areas such as neurodisability, where key competencies were not being met. Others noted that safeguarding responsibilities were disproportionately high, with some doctors in training spending up to 50% of their time on safeguarding cases.

Despite these challenges, several areas of good practice were identified. Supervisors in many specialties were described as approachable and proactive, and there was a strong sense of autonomy in departments such as emergency medicine and infectious diseases. Opportunities for flexible working and working from home were appreciated, and doctors valued the chance to guide their own learning and build skills in areas of interest. Rheumatology was singled out as a particularly positive placement, with a six-week supernumerary period and a strong culture of feedback and support.

When asked whether they would recommend their placement, responses were mixed. While some felt that the educational opportunities outweighed the challenges, others stated that they would not recommend the placement, particularly due to the expectation to cover general paediatrics out of hours. This was described as a “red line” for some, reflecting the depth of concern about the culture and safety of that part of the service.

Consultants in general paediatrics

Educators and supervisors from across the Alder Hey general paediatrics team shared a detailed and candid view of the current educational landscape. There was a clear commitment to supporting the training of resident doctors, but also a recognition of the structural and cultural challenges that continue to impact the delivery of high-quality postgraduate medical education.

Supervisory responsibilities were generally well defined, with educational and clinical supervision roles included in consultant job plans, typically at 0.5 programmed activities (PA). Supervisors reported that these responsibilities were evenly distributed and tracked via internal spreadsheets to ensure equity. However, the volume of supervision required was described as burdensome. Supervisors were often responsible not only for doctors in training but also for advanced nurse practitioners, junior clinical fellows, physician associates and pharmacists, many of whom were not formally recognised in job planning. While most consultants accepted these responsibilities, a small number had opted out.

All supervisors confirmed that they had completed the required training and appraisal within the past 12 months. The trust was reported to fund attendance at Royal College of Paediatrics and Child Health (RCPCH) supervisor study days, and a local refresher course was offered annually. Monthly meetings were held in emergency medicine, and a structured process was in place to identify and support trainees requiring extra support (TRES). A less-than-full-time (LTFT) champion was in post and described as proactive in designing bespoke return-to-work packages, including supernumerary periods and rota adjustments.

Curriculum delivery was seen as variable across departments. Emergency medicine had developed a robust teaching programme, delivering four hours of teaching per week, which doctors in training posts could access regardless of clinical commitments. Supervisors reported that they shared responsibility for curriculum coverage and worked to prevent deskilling by rotating doctors through different areas. In contrast, general paediatrics was described as “relentless,” particularly for doctors in higher specialty training on the higher grade rota, with rota gaps and service pressures limiting opportunities for structured learning. Supervisors acknowledged that the need to maintain service delivery often came at the expense of educational priorities, with specialty clinics sometimes cancelled to ensure general paediatrics was covered.

The issue of service provision versus training came up thematically several times. GRID doctors (i.e. in subspecialty training) were nominally protected during the day, but supervisors acknowledged that they were often pulled into general paediatrics to fill rota gaps. While self-rostering had improved flexibility, it had not resolved the underlying issue of insufficient staffing. Supervisors reported that they had recently taken over responsibility for rota planning and were working on an action plan to address these concerns. However, they also noted that the acute admission bleep (565) remained a challenge, with very few resident doctors able to hold it safely. In some cases, GRID doctors were asked to cover this role as locums, which left them feeling disconnected from the team and unsupported.

As we had heard from the doctors in training previously, we heard again from the consultants that handover practices varied across departments. Emergency medicine had implemented three structured handovers per day and was planning to introduce a fourth. In general paediatrics, consultant presence was maintained until 7pm on weekdays and 3pm at weekends, after which registrars were the most senior clinicians on site. Supervisors acknowledged that over 50% of out-of-hours periods were not directly supervised and that this posed a risk to both patient safety and limited the potential for education and training. Plans were in place to extend consultant cover to 12 hours a day, seven days a week, and this was welcomed by the supervisory team. This change was anticipated to occur in lockstep with an increase in consultant staffing. We were informed that the established consultant body was made up of 10 WTE (ten whole time equivalent consultant hours), though this was practically down to about 7 WTE due to sickness absence over the last year.

Induction was another area identified for improvement. While general paediatrics offered an information pack, lecture, and ward walkaround, the consultants’ view was that doctors in subspecialty training often received less structured introductions. Supervisors noted that a full day of mandatory training would be introduced from September, and that further work was needed to ensure that all doctors in training (particularly those rotating from adult services) were adequately prepared for their roles.

Concerns about lone working in community paediatrics were acknowledged. Supervisors were aware of the issues raised by doctors attending school clinics without chaperones, risk assessments, or clear escalation pathways. They recognised the need to engage with local authorities and review the trust’s lone working policy to ensure that doctors were adequately supported and safe. There was a shared understanding that these placements required more structured induction and oversight.

Overall, supervisors expressed a strong commitment to improving the training environment. They were candid about the challenges they faced, particularly in balancing service delivery with educational responsibilities, but demonstrated a clear willingness to engage with the doctors they were supervising, and to adapt systems and advocate for change. While progress had been made in the delivery of teaching and in supervisor training, there remained significant work to do in addressing rota gaps, improving induction, and ensuring that all doctors in training posts had access to safe, supportive, and educationally rich placements.

Consultants in paediatrics subspecialties

We met with consultants from a range of paediatric subspecialties including gastroenterology, nephrology, oncology, respiratory medicine, rheumatology, emergency medicine, infectious diseases, and community child health. The consultants shared their perspectives on the delivery of GRID training at Alder Hey in a discussion that reflected a strong commitment to education within specialties, alongside a shared concern about the impact of general paediatrics on the quality and consistency of subspecialty training.

Supervisory responsibilities were generally well distributed across departments. We were assured that educational supervision was mostly included in job plans, and though we did hear that gastroenterology was an exception to this we were also told that this service area had job plans currently under review. All consultants confirmed that they had completed educational appraisals within the past year and that the trust provided well-attended training opportunities, including access to training and courses put on by the Royal College of Paediatrics and Child Health.

We learned of a proactive and compassionate approach to providing support for resident doctors with additional needs. Consultants reported that such needs were often identified during initial meetings, and that open conversations were encouraged to ensure appropriate support. Where necessary, the education team was engaged to develop tailored plans. We were given a specific recent case where a trainee requiring extra support (TRES) had their rotation extended for a further six months to accommodate their specific needs.

Curriculum delivery was generally strong within specialties. Oncology GRID doctors were supported to map out their training over a three-year period, including “mini-rotations” through neuro-oncology and solid tumour services to meet curriculum requirements. We were also told of how respiratory, gastroenterology and community child health curriculum needs were met, and the overall approach of supervisors and educators discussing and flagging specific individuals’ needs in a consultants meeting.

A challenge with meeting these complex curriculum requirements included the fact that out-of-hours commitments and service pressures could limit access to certain experiences, as well as the increasing cohort of less-than-full-time doctors who were having to reorganise their personal life in order to access certain educational experiences.

The balance between service provision and training came up again, echoing the sentiments of the general paediatric consultants as well as the resident doctors. This group acknowledged that GRID doctors often took on significant administrative responsibilities and were sometimes required to organise their own rotas. While this fostered independence, it also risked detracting from clinical learning. Several departments noted that they lacked the physical space (e.g. spare clinic rooms) to offer additional training opportunities.

We elected to provide some high-level feedback to the consultants about what we had heard from the resident doctors earlier in the day. The feedback was largely positive and this was well-received, and constructive points of criticism and challenge were accepted.

The relationship between general paediatrics and specialty training was a significant concern. This latter group of consultants made the surprising observation that general paediatrics was the newest and most under-resourced specialty at Alder Hey, and that it had not evolved in line with the rest of the trust. The subspecialty consultants reported that doctors in their training programmes were frequently pulled into general paediatrics to cover rota gaps, reducing their time in specialty and compromising their ability to meet curriculum requirements. This was particularly problematic given the limited number of doctors training in subspecialty areas, and the increasing reliance on junior clinical fellows, who would be expected to take a share of the on-call rota but in practice we heard are sometimes unable to perform at the required level and therefore spend all of their time in the subspecialty.

There was consensus that the solution lay in strengthening the general paediatrics workforce. Consultants supported the current business case for four additional general paediatrics consultants and believed that this would significantly reduce the pressure on subspecialty services. They also acknowledged the need for improved induction processes, clearer risk assessments for lone working in community settings, and more consistent feedback and assessment practices across the trust.

In summary, consultants expressed pride in the quality of training delivered within their subspecialties and a strong commitment to supporting GRID training. However, they also recognised that without structural changes – particularly in general paediatrics – the sustainability of high-quality subspecialty training would remain at risk.

Areas that are working well

The first iteration of self-rostering in some departments (e.g. Emergency Medicine, PICU) had already improved work-life balance and allowed doctors to manage personal commitments.

Good practice

The “chief week” model enabled senior grades to practice working at a consultant level and receive meaningful feedback while supporting junior colleagues.

Areas for improvement

Immediate mandatory requirements

Mandatory requirements

Recommendations

While the success of this first self-rostered rota block can be celebrated, there were delays and clearly learning points that must be incorporated into future iterations of the process.

Trainees reported inadequate facilities, including a lack of office space, rest facilities, and access to phones or administrative support.

Report approval

Report completed by: Zander Zambas, Quality Support Manager
Review lead: Simon Carley, Associate Dean
Date approved by review lead: 9 September 2025

NHS England authorised signature: Raghu Paranthaman, Deputy Dean
Date authorised: 10 September 2025

Final report submitted to organisation: 12 September 2025