Executive summary
The panel thanked the Trust for their participation in this quality intervention, which was arranged to review the quality of the clinical learning environment following the results of the 2024 General Medical Council’s (GMC) National Training Survey (NTS). The panel were grateful for the Medical Education team for their support in the organisation of this review.
During the review, the panel heard feedback from Trust representatives, Foundation doctors, and Clinical and Educational Supervisors in the Trauma and Orthopaedics (T&O) and Emergency Medicine departments. The panel did not meet with clinical or educational supervisors from the school of Surgery or Trainee Programme Directors (TPDs) from the Foundation School.
The Trust explained that they were surprised by the number of red outliers in the GMC NTS 2024 survey and were keen to understand and address the reasons behind them, including conducting their own internal survey for deanery and non-deanery trainees within Trauma and Orthopaedics.
The panel heard that there had been significant service pressures since the COVID-19 lockdown, and this had led to dissatisfaction in workload. However, the Trust reported that there was rarely an issue between Emergency Department, Accident and Emergency (A&E and Specialty teams.
Review overview
Background to the review
This education quality review was arranged following concerns raised via the Kent, Surrey and Sussex (KSS) Foundation School regarding the clinical learning environment within General Surgery and Emergency Medicine and a deterioration in the General Medical Council National Training Survey (GMC NTS) 2024 results.
The review focused on Foundation medical training at St Peter’s Hospital, part of Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH).
Who we met with
Learners
- Doctors in training from Foundation in Surgery and Emergency Medicine training programmes
Educators
- Educational and clinical supervisors in Trauma and Orthopaedics
Education team
- Chief Medical Officer
- Foundation Programme Director
- Director of Clinical Education
- Strategic Head of Medical Education and Knowledge Services
- Divisional Directors for Surgery and Emergency Medicine
- Clinical Tutor
- Clinical Leads for Emergency Medicine
- College Tutors for Surgery and Emergency Medicine
- Guardian of Safe Working
- Clinical Supervisors and Educational Supervisors
Review panel
Education Quality Review Lead
- Dr Peter Anderson, Associate Dean
Specialty Experts
- Dr Paul Reynolds, Head of Foundation School
- Harriet Patmore, Deputy Head of Foundation School
Doctor-in-Training Representative
- Harriet Sharp, F2 Doctor-in-Training in Paediatric Medicine
Lay Representative
- Jacqueline Codrington
NHS England Education Quality Representative
- Alex Bamford-Blake, Education Quality Project Officer
Review findings
Quality Domain 1: Learning Environment and Culture
Induction
When asked about induction, the panel heard that Foundation doctors who stayed on site between their F1 and F2 years experienced a smooth transition. However, those new to the Trust felt their induction did not give them the practical details, such as how to use Datix or exception report, or adequate preparation for on-call shifts, such as on-site orientation, with trainees struggling to know where wards were. FY2 Doctors new to the Trust were not introduced to the Foundation TPDs. Please see Mandatory Requirement MR-05.
It was reported that induction included a 3-hour session on the Mental Capacity Act, which trainees felt was unnecessary as they had been assessing mental capacity throughout their F1 year.
Neither handbook nor induction included the Trust’s Core Clinical Standards which Foundation doctors felt they were assumed to know. Foundation doctors working in T&O felt that their induction to the department was “chaotic” with people stepping in at the last minute to speak to them. There did not appear to be a formal induction process to the department. There is a departmental “padlet”, but it does not cover practical details. Please see Mandatory Requirement MR-04.
When asked about their experience working in A&E, Foundation doctors reported being repeatedly allocated to the same area of the department (either major, minors or Paediatric A&E) and felt “coerced” to stay where they were assigned due to staff numbers.
Emergency Medicine supervisors explained that although the rota coordinator and EPIC (an electronic health record system) determine a trainee’s assignment, supervisors ask trainees which section they have previously worked on to ensure that they get adequate exposure to each area. The panel heard from CS that if a trainee asks not to work a particular section, they are accommodated. It was reported that CS ensure doctors have access to learning opportunities, and that the department try to evenly distribute caseload based on experience or lack thereof. The panel asked the Emergency Department supervisors if they were confident that the current model of allocation of Foundation Doctors to different areas of the department was sufficiently robust to ensure equity of access to training opportunities. The supervisors were confident that the system was robust.
Despite this assurance, there does not appear to be any formal process in place to ensure equity of access to different training opportunities in the Emergency Department. In particular, it was difficult for Foundation Doctors to get access to the Resus area. Foundation Doctors reported that on occasion when a patient that they had been looking after was moved into the Resus area the Foundation Doctor was not allowed to accompany them but was instead asked to remain in Majors seeing other patients. The panel identified that at least two of the Foundation Doctors in the Emergency Department had not had any experience of looking after patients in the Resus area. The Emergency Department supervisors were not aware of this through their own systems. Please see Mandatory Requirement MR-03.
When asked about their experience of Paediatrics A&E, the panel heard that there is no separate Paediatrics A&E consultant and so they must walk to the main A&E for a consultant. It is not always clear to Foundation Doctors which senior emergency department doctor is responsible for supervising the Paediatric Emergency Dept. It was reported that the response to requests for help in the Paediatric Emergency Dept is very variable. On occasion Foundation Doctors found themselves stuck between the ED supervisors asking them to ask Paediatrics for help, and Paediatrics saying that it was not a Paediatric issue, which Foundation Doctors find very stressful, especially during night shifts. Please see Mandatory Requirement MR-01.
With the exception of Paediatric A&E, above, Foundation doctors working in the emergency department reported that they were well supported by seniors leaders.
Foundation doctors in T&O reported that clinical support is variable; some seniors are approachable and responsive and on other occasions it feels like the foundation doctors are running the ward.
Foundation doctors in T&O work some out of hours shifts on the orthopaedic wards at Ashford Hospital. During those shifts there is not a more senior doctor available on site. Patients who become unwell at Ashford hospital are transferred to St Peter’s Hospital. Please see Mandatory Requirement MR-09.
Foundation doctors in Trauma and Orthopaedics reported that they were not often able to join educational opportunities such as outpatient clinics and operating lists due to the workload on the wards.
Bullying and undermining behaviour
The panel heard of instances of undermining behaviour from senior clinicians, and nursing staff in Paediatrics A&E, with one instance of a consultant, after a difficult case, asking Foundation doctors “does anyone want to debrief? You’re not going to cry?” Foundation doctors reported feeling they had to defend themselves from bullying behaviour and justify their own, and the consultants’ decisions to Paediatrics A&E nursing staff. Please see Recommendation R-01.
Foundation Doctors in the emergency department felt there was lack of trust from senior colleagues. There were occasions of consultants being accusatory when trainees called in sick, and occasions of trainees being blamed by them for a decision which had actually been advised by a different consultant. When the panel spoke to supervisors about concerns of bullying and undermining, it was reported that there had been no reports of such behaviour. The panel heard that there is currently no Foundation voice at the quarterly faculty meetings though Foundation doctors are invited.
Quality Domain 2: Educational Governance and Commitment to Quality
In the presentation from the Trust the panel heard that the Trust were surprised by the outliers in the GMC NTS 2024 results as there had been no indication of concerns from either the Local Faculty Group (LFG) or exception reporting data. The Trust reported that they have highlighted avenues for providing feedback to subsequent cohorts to and that they are they are actively encouraging Foundation doctor attendance at the LFG meetings.
The panel heard that an internal survey to deanery and non-deanery Resident Doctors in trauma and orthopaedics was sent at the end of January 2025 to gather further feedback. The findings of the survey were shared in part with the visiting team, but it was agreed that the data would benefit from more analysis before it could be used to inform this intervention.
Foundation doctors reported that they did not know of a formal avenue to give feedback and that, though the ED trainee rep was approachable, there had been difficulty in gathering written feedback for LFGs as most was shared via a WhatsApp group. Foundation doctors said they were unsure what happens with the feedback once given.
When asked if they knew their Guardian of Safe Working (GOSW), the panel heard that the Foundation doctors felt the GOSW was an approachable source of support.
Quality Domain 3: Developing and Supporting Learners
Clinical supervision
When asked about supervision in the T&O department, it was reported that middle grade doctors and SHOs were more available compared to T&O clinical supervisors who Foundation doctors felt could be unapproachable. When asked if they felt confident knowing who to escalate a situation to, the panel heard Foundation doctors feel more comfortable calling the medical registrar than a consultant, as the response from registrar would be “instant and appropriate”, whereas a consultant was more likely to defer to the medical registrar.
Foundation doctors reported that clinical supervisors in the T&O department were not meeting the needs of learners in terms of educational support, including with e-portfolio. Foundation doctors reported that although they had met their named clinical supervisors, they were not approachable. Foundation doctors who had difficulties in achieving their competencies during the T&O placement would bypass their clinical supervisor and go directly to their Educational Supervisors. Educational Supervisors were regarded as excellent.
IT access
It was reported that there were ongoing IT issues with logins and accessing IT support. The panel heard of those returning from community placement had had their logins disabled and only discovered when starting their first shift. The panel heard that the increase in doctors, but limited availability of computers and lack of mobile laptops in the Emergency Department, can affect patient notetaking and has caused prescription errors. Please see Mandatory Requirement MR-06 and MR-07.
Quality Domain 4: Developing and Supporting Supervisors
The panel spoke with clinical and educational supervisors in Emergency Medicine. No Foundation trainers from the T&O department attended the session.
Educational supervisors confirmed they had the required 0.25PA for Foundation supervision in their job plan as well as for Locally Employed Doctors (LEDs). They reported that they attend to Foundation doctors’ concerns as and when required, but that the challenge can be when a trainee requires additional support, and the diversity and confidentiality surrounding said support. The panel heard that, due to pressure to maintain service, CSs felt they alone had to find the balance between workload and job planning for supervision.
Until August 2024, the Trust trialled a funded pilot of Clinical Education Time (CET) which ringfenced time with a Foundation doctor to discuss a case and give systemic feedback. It received positive feedback from both trainees and supervisors, but due to financial constraints the pilot was not extended or instated. Supervisors asked the panel for their support in having CET reinstated within the department. Please see Recommendation R-02.
Quality Domain 5: Delivering Programmes and Curricula
Teaching
When asked about formal teaching, it was reported that there had recently been a push for Foundation doctors to attend formal teaching sessions. However, due to A&E rotation, the panel heard that some Foundation doctors are behind in their teaching hours and that there is no online attendance option, so trainees are unable to attend from home. When asked about the quality of teaching, Foundation doctors reported that they felt it had improved since the start of their rotation. There is an opportunity to give feedback at the end of each teaching session, but there is no facility to communicate what they want from the sessions or their learning needs. When asked who they would consult about a portfolio issue, the panel heard Foundation doctors felt clinical supervisors and senior staff were not approachable and would instead choose their Educational Supervisor. Please see Mandatory Requirement MR-08.
Handover
When asked about their experience of handover, Foundation doctors in T&O reported that though the evening shift is scheduled to start at 8.30pm, trainees are expected to attend handover at 8pm. The panel heard trainees are staying up to 45 minutes after their shift ends to catch up with admin. Please see Mandatory Requirement MR-02. When asked if they are encouraged to exception report in such instances, trainees reported that they had not been told how to do it, or it involved further admin to arrange Time-Off-In-Lieu.
Study leave
The Trust reported that, following dissatisfied feedback in 2022, study leave was easier to access. The panel heard that though some requests do not meet the Trust’s Study Leave guide criteria, the department and the new rota coordinator try to accommodate.
Quality Domain 6: Developing a Sustainable Workforce
This requirement was not specifically discussed as part of the review, however themes in other sections may link to this domain.
Areas for improvement
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| There is not a robust mechanism in place for Foundation Doctors working in Paediatric A&E to access senior medical support. Foundation Doctors in Paediatric A&E find themselves caught between more senior doctors in the Emergency Department and in the Paediatric Department. | There must be a named senior Emergency Department doctor (ST3 or above) on every shift, seven days per week, who is responsible for supporting the Paediatric A&E department. The senior doctor does not have to be located in the Paediatric A&E department but must be available to provide advice and to attend the Paediatric A&E department if required. The name of the responsible doctor must be displayed in the Paediatric A&E department for each shift. Standard operating procedure to meet this requirement to be shared with KSS by 4 July 2025 and actioned immediately after this date. | MR-01 |
| Foundation doctors reported that the night shift started at 2030, but they were expected to attend the handover meeting at 2000. | Clinical handover of the trauma and orthopaedic department must be scheduled within the working hours of resident doctors as set out in the rota. Handover standard operating procedure and resident doctor rota to be shared with KSS by 4 July 2025. | MR-02 |
| The visiting panel identified that there was no mechanism in place to ensure that Foundation Doctors had adequate experience in each of the sub-areas of the Emergency Department. Some of the Foundation Doctors had not had the opportunity to work in the Resus area at all. Others were spending a disproportionate amount of time in the Paediatric A&E. | There must be a process in place to ensure that all Foundation Doctors are getting adequate exposure to all areas of the emergency department including the Resus area. This must be audited every four months and the results shared with KSS Quality by 3 October 2025, 2 January 2026, 3 April 2026 and 3 July 2026. | MR-03 |
| Most Foundation doctors at the Trust spend the full two years of the Foundation programme in the same Trust. A small proportion of Foundation Doctors join the Trust in the FY2 year. These doctors report that they are assumed to have prior knowledge of the Trusts structure and functions, similar to the foundation doctors who spent their FY1 year in the Trust. They were not introduced to the Foundation TPDs or Medical Education department when they joined. | FY2 doctors who are new to the Trust must be introduced to the Foundation TPDs and Foundation programme co-ordinator at induction. Induction for these doctors must include a full explanation of Core Clinical Standards. To be evidenced by a survey of FY2 doctors about their induction experience. To be submitted to KSS by 3 October 2025. | MR-04 |
| Foundation Doctors working in the Trauma and Orthopaedic department initially struggled to understand their role and their relationships with other members of the department. There is not currently a Resident Doctors handbook for the T&O department. | There must be a departmental doctors handbook for Foundation Doctors working in the T&O department. This must include as a minimum: Duties of the postImportant contact numbersEscalation pathwaysLinks to relevant clinical guidelinesA list of the department’s Consultants and their sub-specialty interestsA list of other senior staff including ward managers and departmental managersThe process for reporting sicknessThe process for requesting leave It is recommended that current FY2 doctors are involved in developing the content of the departmental handbook. The handbook should be available for the August 2025 intake of Foundation Doctors. Please share the handbook with KSS by 4 July 2025. | MR-05 |
| The poor access to computers in the Emergency Department prevents Foundation Doctors in the department from working efficiently. There are also potential patient safety concerns where doctors have seen several patients before they are able to access a computer to document the consultations – potential for incorrect documentation. | The Trust must formulate a plan to improve access to computers for doctors in the emergency department. This should include involvement of clinical leads and the risk team. Access to computers must be a standing agenda item for ED LFG for next 24 months. Please share the plan for improving access to computers in the Emergency Dept by 3 October 2025. Please share the minutes of all of the ED LFG meetings held between October 2025 and October 2027. | MR-06 |
| Some Foundation Doctors rotate into community placements for four months of their FY2 year. They find on return to the Trust that their access to IT systems has been revoked which can be difficult and time consuming to sort out. | Foundation Doctors who rotate into community placements must either: Keep their access to Trust IT systems or Have access automatically restored on the first day that they return to the Trust Please share the standard operating procedure to meet this mandatory requirement by 3 July 2025. The procedure should be in place before the arrival of new Foundation Doctors in August 2025. A follow up audit in December 2025 to confirm efficacy should be undertaken. | MR-07 |
| Some Foundation Doctors rotated to A&E are behind in their teaching hours and there is no online attendance option. | The Emergency department rota must take into account the need for foundation doctors to attend sufficient hours of Foundation Teaching OR the foundation teaching sessions must be available to view on-line after the event. Please share the plan for meeting this requirement by 4 July 2025. The Requirement should be met by the time new Foundation Doctors start in August 2025 | MR-08 |
| Foundation doctors in T&O work some out of hours shifts on the orthopaedic wards at Ashford Hospital. During those shifts there is not a more senior doctor available on site | Foundation Doctors must not work without immediate access to senior support. Foundation Doctors must not work at Ashford Hospital unless more senior support is immediately available Please confirm that from August 2025 at the latest, Foundation Doctors will not work without immediate support at Ashford Hospital | MR-09 |
Recommendations
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
| The panel heard evidence of undermining in between nursing and Foundation Doctors in specialist areas of A&E. There have been episodes of trainees being undermined by senior clinicians because they have actioned the decisions of other consultants and been identified by electronic record. We are aware of the important work which is taking place in the Trust to optimise the culture of respect. We recommend that the Paediatric A&E department is included in this work. | R-01 |
| Clinical Education Time was highly valued by educators and by Foundation Doctors. It has been acknowledged that the educational experience in the emergency department has deteriorated since Clinical Education Time was withdrawn. We are aware that many Trusts in Kent, Surrey & Sussex have persisted with Clinical Education Time after the withdrawal of the original central funding. We recommend that very busy clinical areas, including the emergency department would benefit from the re-introduction of Clinical Education Time. | R-02 |
Report approval
Report completed by: Alex Bamford-Blake, NHSE KSS Education Quality Project Officer
Review lead: Peter Anderson, Associate Dean for Kent, Surrey and Surrey
Date approved by review lead: 08/04/2025
NHS England authorised signature: Jo Szram, Postgraduate Dean, KSS
Date authorised: 16 June 2025
Final report submitted to organisation: 16 June 2025