Executive summary
The panel would like to thank the senior leadership team at ASPH for being part of this Senior Leadership Conversation and for their positive engagement in discussions around the quality of education and training for HSTs in Trauma and orthopaedics within their organisation. The visit and subsequent discussions focused on the Trust’s response and actions regarding open mandatory requirements from previous interventions.
The panel expressed satisfaction with the positive engagement and involvement of the Chief Medical Officer and the executive team. They were particularly impressed by the significant progress the Trust made in just two months since the last intervention. As a result, three mandatory requirements were closed, with a few more awaiting the necessary paperwork to be finalised.
The Trust’s new Director of Medical Education (DME) presented detailed actions and steps taken to address specific concerns and open mandatory requirements identified through the last Trainee focus group meeting in April 2025 at the Trust. This report includes details within the relevant sections.
The panel identified areas needing improvement and noted that additional assurance is required to ensure compliance with the standards of the HEE Quality Framework. The seven mandatory requirements outlined in this report will replace the existing requirements established after the previous quality intervention in 2025 and will be monitored through an action plan. The panel concluded that the feedback received during this review indicates significant improvements in the quality of education and training being provided.
In conclusion, the review panel issued one new mandatory requirement around having a standard operating procedure which makes clear that Resident doctors should always first seek advice from the present/current Consultant of the week and a new recommendation regarding Trauma meetings to include invited speakers contributing to the discussions thereby creating valuable training opportunities. The panel would like to receive feedback from HSTs in July and arrange a work programme meeting later in the year.
Review overview
Background to the review
Kent, Surrey & Sussex (KSS) Education Quality arranged this Senior Leadership Conversation due to feedback received from Higher Specialty Trainees (HSTs) in Trauma and Orthopaedics (T&O) at Ashford and St Peter’s Hospital NHS Foundation Trust (ASPH). The feedback was around: alleged poor professionalism and behaviours of the consultant body; lack of training opportunities; day to day problems in working arrangements in relation to rotas; and concerns about a new ‘Registrar of the Week’ system.
KSS Education Quality have previously undertaken an education quality intervention, a Trainee focus group (TFG) on the 9 April 2025, which identified concerns in T&O at ASPH. At the TFG, the review panel heard that the 17-doctor rota at registrar level was causing significant disruption to training opportunities. An immediate mandatory requirement was issued requiring the Trust to restructure the registrar level rota to the current establishment of doctors at this grade, which the panel heard on 9/4/25 was 14 doctors. Nine mandatory requirements were issued which are still open.
This review aimed to understand progress in addressing the concerns raised by the trainees, review progress with existing mandatory requirements, and identify any further quality improvement actions aligned with the NHSE Education Quality Framework.
Who we met with
Education team
- Chief Medical Officer
- Directors of Medical Education
- Head of Medical Workforce
- Strategic Head of Medical Education
- Chief of Service for Trauma & Orthopaedics
- Education Lead – Trauma & Orthopaedics
- Specialty Programme Manager
- Guardian of Safe Working
Review panel
Education Quality Review Lead
- Dr Peter Anderson, Associate Dean
Specialty Experts
- Ms Ginny Bowbrick, Head of School for Surgery
- Mr Matt Solan, Training Programme Director
NHSE Education Quality Representative & Scribe
- Chidi Onyeze, Education Quality Project Officer
Lay Representative
- Martin Brand, NHSE Lay Representative
Review findings
Quality Domain 1: Learning Environment and Culture
Learning opportunities
The Trust reported that the 17-doctor rota which caused significant disruption to training opportunities for HSTs have been re-structured. The panel heard that at the registrar level, the new rota now matches the current establishment of doctors at this grade. This work was undertaken in collaboration with the resident doctors on the registrar level rota and agreed with them. Please see Mandatory Requirement MR-01.
When asked if the Trust had any concerns about having enough training opportunities to go around, bearing in mind that they were increasing from 14 to 16 doctors in August 2025. The Trust responded that they have received approved funding to open more surgical theatres and outpatient consulting rooms to cater for the additional doctors.
The Trust were asked whether they provide adequate access for their resident doctors to participate in outpatient clinics and post-operative follow-up rounds. In response it was reported that there is now one actively allocated clinic per week for HSTs and fellows (locally employed doctors) at registrar level. Registrars would have an individualised case load of a limited number of patients. For example, if there were 15 patients, they might consult with 5 or 6. However, this arrangement applies only to consultant-led clinics, and they would not be undertaking clinics alone. In addition, residents will not conduct elective procedures on their own.
The panel were informed that, starting in August 2025, the Trust will hold research meetings chaired by consultants interested in following up on all quality improvement projects and publications. To ensure residents do not miss out on this training opportunity, they have introduced a new scheduled weekly research session in their rota. Additionally, a research group has been established within the upper limb department to focus on producing significant research.
The panel learned that the ‘Medics Across Continents’ (MAC) programme, which the HSTs raised concerns about due to its impact on their workload, patient care, and potentially patient safety, is currently undergoing a comprehensive review process.
Learning Environment Culture
The visiting team heard that there was felt to be a lack of respect for medical training by service management. Please see Mandatory Requirement MR-03. The panel heard that Trust’s Directorate Leads will engage with all Consultants in the Trauma & Orthopaedics (T&O) Department and the service managers to emphasise the significance of fostering a supportive and respectful team culture. This initiative aims to cultivate an environment where open communication, empathy, and mutual respect are paramount.
The Trust reported that the CMO is to meet with T&O Consultants as a group to address the matter of respect more formally and will ensure that all are spoken to individually. The panel learned that a draft letter has been prepared to be sent out to the service team. Subsequently, there will be check ins with the Residents and Locally Employed Doctors to ensure that respectful behaviours are being maintained. Please see Mandatory Requirement MR-02.
When asked about the ownership of patients, the panel heard that a consultant always takes responsibility for each patient. The Trust revealed that they have implemented a “consultant of the week” system, meaning that any patient admitted during that week falls under that consultant’s responsibility. The panel learned that resident doctors do not feel pressured in this system, as the approach is always consultant-led. The Trust intend to work with resident doctors to identify how educational opportunities can be developed for the next cohort of HSTs.
The CMO mentioned that there are multidisciplinary trauma meetings held in the mornings, featuring various specialties and subspecialties. These meetings provide an opportunity to discuss new or challenging cases while benefiting from expert input. The panel noted that attendance among HSTs has improved, with more individuals starting to return. The Trust has established both short- and long-term goals to address cultural issues, which include initiatives like individual training and various courses.
The DME also spoke about encouraging participation in the Residents’ Forum and the LFG as well as informal discussions on the “shopfloor”, being more visible by walking around departments and engaging in conversations with staff as ways of improving culture in the learning environment.
The panel emphasised the importance of encouraging resident doctors to assume leadership roles as it would be beneficial for them to receive recognition for their contributions to their portfolios and support those who take on these responsibilities. However, there needs to be a clearly identified consultant who they know they can go to for advice and support.
Resident doctor handover
The Trust confirmed that the resident doctors’ work schedules now incorporate the 7.45am start time to reflect the start of handover. The issue regarding handover after the seven-day stretch, especially on the subsequent zero day is being addressed to allow for handover the day before. There will be no expectation for staff to come in on their zero day.
Quality Domain 2: Educational governance and commitment to quality
Escalation policy
The panel heard that the department will develop a clear escalation policy for inpatients on the Ashford site to share with medical staff by end of June 2025. When asked about the availability of doctors on-site for patient care, particularly on Sunday afternoons, the Trust explained that they currently do not operate at the Ashford site on weekends. The panel learned that inpatient services are suspended on Saturday at lunchtime, and any remaining patients are transferred to St. Peter’s for continued care. The Trust schedules more complex cases earlier in the week, from Monday to Friday, to ensure that patients can go home by the weekend. Additionally, they handle many of the less complex trauma cases at Ashford.
The panel was informed that for the Trust’s elective surgical hub located at Ashford, the requirement for managing patients there is to have a clinical nurse site practitioner who is ALS (Advanced Life Support) trained, along with one of the resident doctors who is also ALS trained. The policy stipulates that if a patient is identified as sick, they are to be transferred to the St Peter’s site. Please see Mandatory Requirement MR-04.
The panel learned that discussions are underway to provide better insight into the operations within the Departments, ensuring that the induction process aligns with the policy for any group arriving at the site to work.
Exception reporting
The Trust reported that a teaching session was delivered at the Induction Programme explaining the process of exception reporting in October 2024. However, during this year’s induction a session will be delivered by the Guardian of Safe Working, who will highlight the importance of exception reporting missed education opportunities for the benefit of all; this has been shared with resident doctors by email.
The panel was informed that the Trust has transitioned to an app for exception reporting. They held a training event to share this new information with all the doctors in the Trust. The Trust stated that the feedback has been positive, particularly because the app indicates where the exceptions are originating from, whether from specific wards or Trust sites. Overall, the response has been encouraging.
Quality Domain 3: Developing and supporting learners
Senior supervision and support
The panel heard that due to the way that the trauma take works, it is not always clear to Resident doctors which Consultant has overall responsibility for the care of each individual patient. For example, a trauma patient may be admitted under one Consultant of the week, operated on by another trauma Consultant, and be re-admitted with a wound infection by a different Consultant of the week. Resident doctors previously reported being asked to speak to several different Consultants when seeking advice for the management of these patients. Please see Mandatory Requirement MR-07 (New).
In response to the question about the nature of support for resident doctors in the Trust, the Panel heard that there is a consultant-led ward round that takes place from Monday to Friday at 2:00 PM. This timing allows for the involvement of ward nurses, consultants, physiotherapy, and the availability of blood results.
When asked about the usefulness of a recent survey conducted among residents at various levels, the Trust reported that residents felt appreciated and empowered. There are plans to repeat the survey in July and to continue monitoring every three months.
When asked about the percentage of cases that residents handle in the hub, the Trust stated that they did not have exact numbers. However, they mentioned that trainees are always paired with consultants who provide them with cases to work on. The Trust reported that historically, they have had strong participation rates at ASPH, which has been acknowledged by many trainees and a lot of them express a desire to join ASPH because of these positive experiences.
Additionally, the panel heard that the HSTs would mostly recommend their post, giving the reason that despite the cultural issues mentioned, the training received on an individual basis, particularly in the operating theatre, was excellent. They provide good training opportunities and are willing to let registrars take the lead during surgical procedures. It was reported that the HSTs were particularly complimentary about the Upper Limb Team clinical lead and the newly appointed divisional lead, who is an anaesthetist and has been approachable and interested in their concerns.
College tutor appointment
The Trust was asked whether they would involve the Deanery in the recruitment of a college tutor, and they responded positively. The panel requested that this recruitment not be limited to just the interim period and enquired about the expected duration of the interim appointment before a long-term college tutor is appointed. The Trust was uncertain about the timeline. The panel emphasised the importance of the Deanery being included in this process, as the appointment is crucial for the current work programme. Please see Mandatory Requirement MR-05.
Quality Domain 4: Developing and supporting supervisors
This requirement was not specifically discussed as part of the review, however themes in other sections may link to this domain.
Quality Domain 5: Delivering programmes and curricula
Work schedules
The Trust confirmed that all Residents were issued with work schedules but are unable to determine whether they have been individualised for this year’s intake. Medical Education will ensure that this is completed for the 2025 intakes.
The panel heard that the Trust has a reliable system that allows everyone to access the rota on their phones. If there are any changes, the system automatically alerts users, and the feedback has been excellent. Additionally, the Trust noted that in the new rota, each individual’s title is embedded, making it clear what each doctor’s role is, even if the non-clinical rota coordinator is not familiar with them.
The Trust reported that they ensure less than full time resident doctors receive adequate exposure to all necessary areas. They also incorporate any timing changes into their schedules.
Quality Domain 6: Developing a Sustainable Workforce
Rota
The panel heard that the trust leadership now has more clinical oversight over the rota allocation. The trust informed the panel that there is a new co-ordinator structuring the rota as well as a registrar allocated to ensure rota is clinically appropriate for the training of the HSTs. The panel heard that there has been good informal feedback that the trainees are much happier.
The panel was informed that senior management apologised to the residents for not recruiting or sorting out rota issues on time. The trust immediately offered to reduce the rota to represent the working posts or the alternative of an August start with a secure 1 in 16. The panel heard that the HSTs decided to stay on their current rota and start with a 1 in 16 structure in August, and a new rota was in place within a week of that discussion. Further to this, the rota was sent to the trainees to choose their lines of work aligning with their already booked annual leave.
The panel learned that two people have already been recruited to start from next year as a contingency plan against any sudden changes to staffing. Please see Mandatory Requirement MR-06.
Areas for improvement
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| The panel heard that the Trust now has more clinical oversight over the rota allocation. The Trust informed the panel that there is a new specific operational team co-ordinator, as well as a registrar allocated to ensure rota is clinically appropriate for the training of the HSTs. | The Trust must provide rota for October 2025 for new residents, which will be published 8 weeks ahead, with any gaps highlighted. Please provide an updated rota for the quarterly monitoring period, 3rd October 2025. | MR-01 |
| The visit team heard that the atmosphere during the trauma meetings has created an uncomfortable and unproductive environment, where learning opportunities are overshadowed by personal conflicts. | The Trust medical directorate leads to meet 1-2-1 with all consultants. All consultants within trauma and orthopaedics to undertake joint civility training from a recognised provider – NHSE can provide suggestions. Trust to provide NHSE with the plan for all staff within Trauma and Orthopaedics to complete Human Factors training. The surgeon who is due to operate must be present at the trauma meeting 100% of the time. This will allow Resident doctors and others in the MDT to understand why a particular operation is chosen. The “consultant of the week” must actively and proactively chair this meeting, with appropriate, specifically nominated deputisation to another consultant if required, focusing on behaviours and culture as well as workload and decision making. Documentary evidence to be submitted by 3rd October 2025. | MR-02 |
| The visiting team heard that there was felt to be a lack of respect for medical training by service management. | The CMO and Service clinical leads are required to raise this issue with the corporate teams within services in written form and provide evidence of this communication to NHSE. A plan for how to ensure educational opportunities are provided within the service must be developed and provided to NHSE for the next cohort of HSTs. Please provide an update for the quarterly monitoring period, 3rd October 2025. | MR-03 |
| The panel heard that the Department will develop a clear Escalation Policy for patients on the Ashford site to share with Medical Staff by end of June 2025 | The Trust is required to provide an escalation policy for unwell patients under the care of Trauma and Orthopaedics on the Ashford site that addresses the concerns raised by the resident doctors in the department at this review, specifically around consultant responsibility. Please provide an update and documentary evidence for the quarterly monitoring period, 3rd October 2025. | MR-04 |
| The Panel heard that the ASPH will put an interim experienced educational lead in place until a permanent solution can be found after the Summer. This is to ensure Educational Governance and Local Faculty Group Structure within Trauma and Orthopaedics are functioning to meet the needs of learners. | The Trust to provide evidence of a revised Local Faculty Group and educational leadership structure within Surgery to ensure that feedback can be received and managed appropriately through these meetings. Trust to involve Deanery in the recruitment of new educational lead. Please provide an update for the quarterly monitoring period, 3rd October 2025. | MR-05 (previously MR–06) |
| We can confirm that all Residents were issued with works schedules but are unable to determine whether they have been individualised for this year’s intake. Medical Education will ensure that this is completed for the 2025 intakes. | The Trust to provide evidence that all work schedules within Trauma and Orthopaedics have been reviewed and signed off by resident doctors in training as meeting educational requirements of the programme they are in. Please provide an updated rota for the quarterly monitoring period, 3rd October 2025. | MR-06 (previously MR-07) |
| Due to the way that the trauma take works it is not always clear to Resident doctors which Consultant has overall responsibility for the care of each individual patient. For example, a trauma patient may be admitted under one Consultant of the week, operated on by another trauma Consultant, and be re-admitted with a wound infection by a different Consultant of the week. Resident doctors report being asked to speak to several different Consultants when seeking advice for the management of these patients. | In the interests of patient safety, and to prevent confusion and anxiety for Resident doctors. There needs to be a standard operating procedure which makes clear that Resident doctors should always seek advice from the present/current Consultant of the week (highlighted in induction). If input or clinical leadership is required from another surgeon that will be arranged by a Consultant-to-Consultant discussion, and the resident must not be expected to act as a messenger. Please provide an updated rota for the quarterly monitoring period, 3rd October 2025. | MR-07 (New) |
Report approval
Report completed by: Chidi Onyeze, Education Quality Project Officer, KSS
Review lead: Dr Peter Anderson, Associate Dean
Date approved by review lead: 27 June 2025
NHS England authorised signature: Professor Jo Szram, Postgraduate Dean, KSS
Date authorised: 31 July 2025
Final report submitted to organisation: 18 August 2025