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 concerns raised during the interim review process for the Higher Specialty Trainees (HSTs) in Trauma and Orthopaedics within the School of Surgery. The panel was grateful to the Medical Education team for their support with the organisation of this review. 

During the review, the panel heard feedback from Higher Specialty, Core and Foundation Doctors in the Trauma and Orthopaedics (T&O) department.  and a number of locally employed doctors (LEDs) working at SHO and registrar level.

The panel heard the following: 

• A prolonged period of poor rota management at the registrar level has led to an increasing workload and insufficient training opportunities. The operational demands of the new Ashford Elective Surgical Hub have HSTs’ exposure to the required curricular training opportunities. This has also potentially had an impact on patient safety.
• The learners reported unprofessional behaviours by a small proportion of the consultant surgeons in the T&O department of ASPH, which have had a negative impact on trainees. They also described a challenging culture within the service management team, with a perception that training is not seen as a priority.
• The learners felt supported by the Upper Limb Team clinical lead and the newly appointed divisional lead.

Due to the time-critical nature of the rota management concern, Mandatory Requirement 01 (MR-01) was communicated the following week via email to the Trust Chief Medical Officer and Director of Medical Education.

Review overview

Background to the review

This education quality intervention was arranged following concerns raised via the Kent, Surrey and Sussex (KSS) School of Surgery regarding the clinical learning environment within Trauma and Orthopaedics. This was following the interim review process for the Higher Surgical Trainees conducted by the School of Surgery.

The review focused on Higher Specialty Trainees, Core and Foundation Doctors working in Trauma and Orthopaedics at both St Peter’s Hospital and Ashford Hospital, of Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH). 

Who we met with

Learners

• Trauma and Orthopaedic Foundation, Core and Higher Specialty Doctors in Training
• Locally Employed Doctors at SHO and Registrar level
  
  

Education team

• Dr Clarence Chiksuku, Director of Medical Education (due to take up post shortly after following this visit), Ashford and St Peter’s NHS Foundation Trust (ASPH)
• Dr Philip James, Clinical Tutor, ASPH (due to demit post shortly after this visit)
• Helen Ellis, Medical Education Manager, ASPH

Review panel

Education Quality Review Lead   

• Prof Jo Szram, Postgraduate Dean, Kent, Surrey & Sussex (KSS), NHS England (NHSE)
• Ms Ginny Bowbrick, Head of School of Surgery KSS, NHSE

Specialty Expert     

• Mr Matt Solan, Training Programme Director, Trauma and Orthopaedics, School of Surgery KSS, NHSE

NHSE Education Quality Representative(s)      

• Rosie Courtney, Senior Workforce Specialist, Simulation and Patient Safety, NHSE

Review findings

Quality Domain 1: Learning Environment and Culture

Learning opportunities

The panel heard of an issue in the SHO level rota which the foundation doctors and core surgical trainees work on. The SHO of the week undertakes 7 days in a row starting on a Friday morning and finishing on a Thursday afternoon. The next day should be zero hours, but they reported that they are frequently called to attend the handover at 7:45 the next morning. In addition, the current work schedules and pay give an 8am start time, which is not correct. Please see Mandatory Requirement MR-01.

The HSTs reported to the team that there had been a delay in the opening of the Ashford Elective Surgical Hub and that the overstaffing needed to cover the elective lists led to a decline in training opportunities. The HSTs explained that they are often pulled from their training activities to cover a variety of other tasks, at short notice, which impacts their ability to gain the necessary experience and skills.

The panel heard that the medical care of patients located in the Ashford Hub at night had an unclear escalation policy and a lack of continuity of care was noted. Some HSTs said they would not feel comfortable having family members treated overnight at the Ashford Hub. Please see Mandatory Requirement MR-04.

The HSTs raised concerns about the ‘Medics Across Continents’ (MAC) programme as the MAC doctors need a higher level of support than the usual from them, as they are new to the UK and the NHS, which impacts on the workload of the HSTs, patient care and potentially patient safety.

Learning environment culture

The panel heard the atmosphere during the trauma meeting described as ‘toxic’ and ‘adversarial’. It was reported that the meetings often involve negative conversations and disagreements among consultants. This has created an uncomfortable and unproductive environment, where important discussions are overshadowed by personal conflicts. The HSTs also felt that they have been belittled in trauma meetings which has led to them not asking questions and at times avoiding attending altogether which has led to them losing out on potential learning opportunities. They felt that these meetings were not supportive of the best patient care. Please see Mandatory Requirement MR-02.

When asked about the approachability of consultants, the HSTs noted that while most consultants are approachable and supportive in the operating theatre, the overall management and communication issues have created a challenging work and learning environment.

The panel heard that the HSTs felt there was a lack of respect for the requirements of medical training by corporate management. The HSTs felt overly depended on for service provision leading to learning opportunities being lost. Please see Mandatory Requirement MR-03.

The HSTs stated that they 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. The HSTs were particularly complimentary about the Upper Limb Team clinical lead and the newly appointed divisional lead, who is an anesthetist and has been approachable and interested in their concerns.

Quality Domain 2: Educational Governance and Commitment to Quality

The panel asked whether the HSTs were aware of the opportunity to report missed educational opportunities; this wasn’t felt to be clear, nor that these should be recorded and escalated via the Exception Reporting System. There was a mixed response to this, citing “clunky” software as the main impediment to exception reporting, as well as not wanting to be seen as causing issues.  Please see Mandatory Requirement MR-05.

When the doctors were asked who the Surgical College Tutor was, there was uncertainty as to who was in this position. The panel heard that the Local Faculty Group (LFG) was an unwieldy meeting, and it was felt that as there were too many people present, the HSTs did not feel that they had the opportunity to raise their issues.

Quality Domain 3: Developing and Supporting Learners

Induction

The Foundation doctors were asked about induction. They confirmed that they had all received standard Trust induction and found it useful. The departmental induction was held as a document on a Padlet (website) designed by a previous fellow, which has some presentations stored on it.

The panel asked the Foundation doctors if they had felt prepared to undertake on-calls. It was raised that many felt unsure of the role when they started including basic information such as which wards they were responsible for covering. It was raised that occasionally they have been asked to do a ward round on their own as a F1 or F2. The panel asked if they had been expected to cover gaps in rotas and all Foundation doctors responded ‘yes’.It was noted that whilst the Trauma Meetings started at 7:45am, they were only paid from 8am despite the doctors being expected to attend. Please see Mandatory Requirement MR-08.

The HSTs were seen by the SHO level doctors to be very approachable. The SHOs also felt that they could phone most – but not all – of the consultants should they need them, but as the HSTs are so responsive, they did not need to do so.

It was raised that there was some duplication of departmental presentations during the teaching programme.

Quality Domain 5: Delivering Programmes and Curricula

Work Programmes

It was reported that attempts from HSTs to discuss issues with their individualised work programmes had led to undermining by senior management personnel, with one HST being told they were “behaving selfishly”. There was a concern that the issues with their work programmes and lost training opportunities could lead to non-standard outcomes at ARCP including extensions to training. Please see Mandatory Requirement MR-07. 

Quality Domain 6: Developing a Sustainable Workforce

Rota

The HSTs raised issues with the current rota arrangement for the service.  They had been informed that the position of a ‘registrar of the week’ on the rota was a new position in the service, with multiple goals of improving patient continuity, minimising disruption to the working week and affording educational opportunities in ward management of patients (a curriculum Capability in Practice (CiP)).

They further explained that the rota is currently modelled on a 1 in 17 even though there are currently only 13 doctors employed to work on this rota. This has led to HSTs not knowing where they will be working up to 10 days in advance with some changes made at shorter notice. This has led to low morale, a negative impact on training, and significant operational challenges that have impacted patient care, and potentially safety. Examples given included HSTs being pulled from elective lists to cover on-call gaps, affecting both their training and the overall functioning of the department. Please see Mandatory Requirement MR-09.

It was reported to the review team that management have not given an indication for the reason for the current rota modelling and HSTs have offered to help improve the rota which has been rejected. The panel heard that the HSTs felt disrespected as professionals by the management team due to this approach, as well as several instances of the HSTs being sent to the wrong location, which in turn impacted on the timing of the working day, a rushed handover and loss of training opportunity.

Consultant of the week

There was a perception raised by the Registrar and SHO level doctors that consultants were not taking ownership of patients as part of the current system, leaving the staff unsupported due to lack of clarity of escalation. This was described as an unusual process, whereby the ‘consultant of the week’ is expected to take ownership of the patients that a different consultant had operated on, leading to a plurality of ownership or acceptance of responsibility for decision making.

The panel heard that the role of ‘registrar of the week’ involves significant responsibilities, including ward rounds, on-call duties and managing more junior staff. This role, while providing some learning opportunities, also places a heavy burden on HSTs which has limited their ability to focus on their training

Areas for improvement

Mandatory requirements

Report approval

Report completed by: Rosie Courtney. Senior Workforce Specialist, Simulation and Patient Safety
Review lead: Jo Szram, Postgraduate Dean for KSS
Date approved by review lead: 28 May 2025

NHS England authorised signature: Jo Szram, Postgraduate Dean for KSS
Date authorised: 28 June 2025

Final report submitted to organisation: 16 June 2025