Executive summary

Following the suspension of training of foundation resident doctors (RDs) from the General Surgery department at Barnet Hospital, the review panel sought reassurance that foundation RDs in Trauma and Orthopaedics had not been adversely affected, and to understand what impact the suspension of foundation RDs in General Surgery had had on that department, particularly the educational opportunities afforded to core and higher specialty RDs still working in General Surgery.

One Immediate Mandatory Requirement (IMR) was issued to ensure that all medical staff working within General Surgery were aware of the function of the Freedom to Speak Up Guardian (FTSUG) and how to access them.

Other concerns identified included:

• The consultant body reported inequitable distribution of the Surgeon of the Week (SoW) duties across the whole cohort. It was suggested that those working a reduced clinical component of their role were exempt from undertaking this duty, rather than all consultants participating a proportionate amount of their clinical time to this duty.
• Core and Higher General Surgery RDs reported having concerns around meeting the required number of theatre sessions and clinics whilst in post to meet their curriculum requirements.
• The review panel noted a reluctance among all RDs to use the sleep pods available, noting that it was not clear if the pods were occupied, and that hygiene was a problem as it was not clear how often they were cleaned or any bedding changed.
• Consistent with previous quality reviews to Barnet Hospital, it was reported that some RDs experienced significant delays in obtaining a parking permit.

This review also identified a number of areas that were working well:

• Foundation RDs in Trauma and Orthopaedics (T&O) reported a positive training experience, describing their senior colleagues as supportive and approachable. There were distinct boundaries between T&O and General Surgery and the few interactions there had been, were described as courteous and generally positive.
• The Organisational Development (OD) initiatives to address the cultural concerns in General Surgery were viewed as a positive and valuable team building exercise by the consultant body.
• The deployment of Medical Support Workers (MSW) within General Surgery had been viewed as a positive development, with the consultant body wanting to see MSWs formalised into the departmental staffing model on a permanent basis.

The panel assigned provisional Intensive Support Framework (ISF) ratings for the following programmes:

• General Surgery – Foundation Training: ISF 4 (training suspended in March 2024)
• General Surgery – Core and Higher Specialty Training: ISF 2
• Trauma and Orthopaedics – Foundation Training: ISF 0

Whilst the review panel was encouraged to hear of changes being implemented in the general surgery department, the specialty remains under General Medical Council (GMC) Enhanced Monitoring with conditions attached to GMC approval of posts in the general surgery department at Barnet Hospital until further sustained improvements have been evidenced in relation to outstanding concerns and those identified during this review.

NHS England’s Education Quality Team will monitor the responses to the mandatory requirements detailed in this report during the quarterly Quality Management Portal (QMP) action cycle.

Review overview

Background to the review

This was a follow-up Learner and Educator Review of General Surgery and Foundation Surgery at Barnet Hospital.  

An initial urgent concern learner review of Foundation Surgery on 13 March 2024 resulted in foundation training in General Surgery being suspended at Barnet Hospital due to the learning environment and department culture being deemed unsafe and detrimental to learner safety. These foundation RDs were relocated within the Trust for the remainder of their rotation. The department was placed in General Medical Council (GMC) Enhanced Monitoring in March 2024, with conditions attached to GMC approval of posts in the General Surgery department at Barnet Hospital. 

This follow-up Learner and Educator review was undertaken to establish the trust response to departmental culture issues in General Surgery and to establish the impact suspending training of foundation RDs had on core and higher surgery RDs still in the department. The review panel also sought to meet with foundation RDs in Trauma and Orthopaedics to see what impact, if any, this had on them.    

Who we met with

Learners

• 5 foundation RDs in Trauma and Orthopaedics
• 12 core and specialty RDs, Locum and Locally Employed Doctors (LEDs) in General Surgery
• 4 MSWs in General Surgery

Educators

• 5 Clinical and Educational Supervisors for General Surgery
• 2 Educational Supervisors for Trauma and Orthopaedics

Education team

• Co-Director of Medical Education (Barnet Hospital)
• Co-Director of Medical Education (Barnet Hospital)
• Head of Quality Postgraduate Medical Education
• Medical Education Manager
• Medical Education Coordinator
• Education Lead for Trauma and Orthopaedic Surgery
• Freedom to Speak Up Guardian
• Guardian of Safe Working
• Medical Director
• Education Leads for General Surgery
• Divisional Director of Operations for Surgery and Associated Specialties
• Clinical Director for General Surgery
• Service Line Lead for General Surgery
• Clinical Director for Trauma and Orthopaedic Surgery
• Senior Operations Manager for Emergency, General and Colorectal Surgery and LGI Cancer
• Assistant Director of People
• Director of Undergraduate Medical Education for Royal Free Campus, University College London Medical School

Review panel

• Prof Vivienne Curtis, System Dean, North Central London, NHS England
• Miss Celia Theodoreli-Riga, Head of School of Surgery, NHS England
• Dr Alice Carter, Associate Dean, Foundation School, NHS England
• John Marshall, Education Quality Manager, NHS England
• William Henderson, Education Quality Assurance Programme Manager (London), General Medical Council
• Dr Malcolm Gajraj, Enhanced Monitoring Associate, General Medical Council
• Sarah-Jane Pluckrose, Lay Representative

Review findings

The review panel thanked the Trust for facilitating this review.

In the session with the Trust leadership the review panel heard presentations from both General Surgery and Trauma and Orthopaedics.

General surgery

The General Surgery presentation gave an overview of current departmental staffing and the action taken, and still to be taken, following the IMRs in March 2024. The review panel heard that the consultant body were informed of the suspension of training of foundation RDs and the reasons for this action. Weekly meetings were set up with the Trust executive to outline the department’s response and the service improvement plan.

The review panel heard that increased clinical supervision provision had been implemented with the recruitment of two additional consultants, one substantive and one locum. To mitigate the loss of foundation RDs the service was augmented with the addition of MSWs. Rotas were restructured for core and higher specialty RDs, fellows and LEDs, with consultant oversight into the design of rotas. It was reported that clear departmental leadership roles had been introduced to include the separation of the Clinical Director and Service Line Lead, the appointment of undergraduate and endoscopy leads, changes to the SoW ward round, and the creation of two SoW teams, one consultant-led and the other registrar-led. It was acknowledged by the Trust that prior to March 2024 the department had been understaffed, but that financial support was put in place to ensure the sustainability of the service in the absence of foundation RDs. The review panel heard that 11 junior clinical fellow posts were currently being advertised to avoid the reliance on temporary staff. The review panel heard that staffing across the Trust did not reflect recent increases in the size and profile of the population it served. It was also noted that a business case to increase staffing levels and to expand the medical liaison service to improve patient care, as well as education and training, was being submitted to the Trust executive. In response to the concerns that led to the suspension of the foundation RDs, it was confirmed that three members of staff were no longer working in the department.

To address the concerns arising from the urgent concern review in March 2024, and the subsequent GMC National Training Survey (NTS) results, the review panel heard that the consultant body had engaged well with externally facilitated OD sessions to address concerns around the departmental culture and to foster a cohesive team ethos. It was noted that similar sessions were planned for RDs and the wider multidisciplinary team (MDT), with a view to bringing the two groups together to continue this work. It was reported that escalation policies had been expanded and that regular feedback from RDs and others was sought by the Postgraduate Medical Education Team (PGME), with the roles of the Guardian of Safe Working (GOSW) and FTSUG reaffirmed to all staff.

To address concerns around safety and security, particularly out of hours, it was reported that additional rest areas in theatres had been designated, in agreement with the Head of Nursing and Theatres.

Other initiatives to improve departmental cohesion and the education experience included fortnightly MDT meetings, education becoming a standing agenda item at the monthly consultant meetings, greater RD involvement in Local Faculty Group (LFGs) meetings, the restructuring of the morning handover, changes to rotas to ensure more access to theatre and clinic opportunities, the reinstatement of monthly morbidity and mortality meetings, and the establishment of a Fellowship of the Royal College of Surgeons teaching group.

The review panel heard that undergraduate medical students had returned to the department in September 2024, following an initial pause. It was reported that feedback from this group about their experiences within General Surgery had been positive.

Trauma and orthopaedics (T&O)

The review panel heard an overview of the departmental structure and education offer across the Barnet (emergency) and Chase Farm (elective) Hospital sites. It was noted that the departmental induction was flexible and could be undertaken throughout the year based on individual need, but otherwise was aligned to follow the August corporate induction, and included introduction to clinical areas, curriculum delivery, accessing support and reporting systems. It was reported that there was a range of formal and informal learning opportunities, with scheduled teaching on Wednesday afternoons, journal clubs and informal teaching as part of ward rounds. In addition, foundation RDs were released for foundation programme teaching.

The review panel heard that the redeployment of general surgery Foundation RDs, had a positive impact on the T&O department and supplemented the established staffing numbers well. It was reassuring to hear that the additional foundation RDs had not diminished or led to greater competition among RDs to access learning opportunities and that the capacity to support these additional foundation RDs had not put undue pressure on clinical or educational supervision.

In the discussion after both presentations the review panel followed up on a number of areas. It was noted that the suspension of training of foundation RDs from General Surgery had had significant impact on staff morale, particularly at a senior level, and whilst initially challenging, once mitigations were in place, feedback from the remaining RDs and LEDs had improved, with no new concerns identified around bullying and harassment. However, it was acknowledged that there was still work to be done in around raising concerns for all staff within the department.

The review panel sought reassurance from the Trust that there was a sustainable and suitable case mix within General Surgery for RDs to meet their curriculum requirements. It was reported that despite scheduled cancer surgery having moved the Royal Free site, it was felt that the case mix within Barnet Hospital, and the opportunity for RDs to accompany consultants to the Royal Free site for cancer cases, was appropriate, especially for years three to five specialty training grades (ST3-5). The Trust was encouraged to develop and ensure that this model was sustainable, and it was noted that case numbers determined the viability of post allocations, with a view to post redistribution considerations already underway.

T&O Foundation RD session

The review panel was pleased to hear that foundation RDs in T&O were positive about their posts and educational experience. It was noted that the consultant body was supportive and approachable and that there were no concerns regarding bullying and undermining. Whilst this group was aware of the issues that led to the suspension of their foundation colleagues in General Surgery from March 2024, it was unable to provide significant feedback to the review panel around General Surgery. The review panel was reassured that foundation RDs in T&O had not been asked to cover General Surgery and were aware that, if they had been asked, it would not be appropriate for them to do so whilst foundation training in General Surgery was suspended. It was noted that foundation RDs in T&O stated that they felt distinctly separated from their General Surgery colleagues and were unclear whether this was by design or in response to the cultural and safety concerns within General Surgery.

It was also reported that there were no issues around clinical supervision and that the non-resident registrar out of hours was generally responsive when required. Overall, it was noted that clinical supervision was good and that foundation RDs felt supported by their senior colleagues and consultants.

The review panel was pleased to hear that this group would recommend their training posts to their peers and that they would be happy for their friends and family to be treated in the department, noting that there were good opportunities to attend theatre and clinics. The one area of caution raised was that in some cases it had been a challenge for foundation RDs to schedule their initial meeting with their educational supervisor. It was also noted that there was a reluctance to use the sleep pods provided in the doctor’s mess as it was unclear if the pods were occupied.

General Surgery RDs, LEDs and Medical Support Workers session

The review panel met with a mixed group of former and current core and higher specialty RDs, as well as locums, LEDs and MSWs working in General Surgery. This enabled the panel to understand how the department functioned following the suspension of training of foundation RDs in March 2024. Those that had recently joined the department reported receiving a warm welcome, which allayed their apprehension prior to starting in their post. For those that had been in the department in March 2024, there had been a notable improvement in the culture. The efforts of the Trust and department leadership to address the concerns raised was acknowledged. The review panel was encouraged to hear that clear escalation pathways had been established and that RDs did not have any concerns seeking out senior support.

This group did however note that there was a general concern around achieving the required theatre lists and clinics, in line with their curriculum requirements. This experience was mixed, with some stating that they had had good access to routine, low complexity cases, similarly reflecting the Trust leadership’s view that there were good learning opportunities for grades ST3 to 5. It was felt that the significant turnover of staff was due to the nature of the work on offer and that increased endoscopy lists – something the Trust was looking to address – would improve the learning experience as well as staff retention. It was also noted that elective cases were mainly scheduled at the Royal Free and Chase Farm sites resulting in the majority of work at Barnet site being emergencies and on-call, out of hours cases. It was noted that some within the consultant body were receptive to these concerns and made themselves available to discuss case numbers. The review panel felt that resident doctors would benefit from being signposted to the General Surgery College Tutor at Barnet Hospital, as a means to ensure that educational and curriculum requirements were being met for all RDs. The group also noted that the LFG had proved to be a valuable forum for raising and addressing issues, acknowledging that some issues were easier to resolve than others. This group recognised the effort and desire of the Trust to change and develop a more cohesive departmental culture within General Surgery.

The review panel was pleased to hear that there had been no experience of bullying and harassment within the group, nor had they witnessed others being subject to such behaviour. Although it was agreed that they had no concerns raising a concern around bullying and harassment, it was noted that none present knew of the role of the FTSUG and how to access them. This was in contrast to what the review panel had heard earlier and led to the issuing of an Immediate Mandatory Requirement (IMR).

Similar to their foundation RD colleagues in T&O, this group also had reservations around using the sleep pods provided, noting concerns around hygiene and the frequency of which they were cleaned and bedding replaced. In keeping with previous quality interventions to Barnet, the issue of car parking arose. It was reported that some had had to chase for months at a time to be issued with the required parking permit. Experience of this was variable, with some receiving their permits in a timely manner.

RDs amongst this group were hesitant when asked if they would recommend their training posts to their peers, and the wider group would only be happy for their friends and family to receive treatment in certain scenarios and times of day.

Supervisor session

The review panel recognised the anguish and distress of the educational and clinical supervisors as a result of the suspension of foundation RDs from General Surgery. There was a palpable sense of frustration, and it was reported the news was a shock at the time. In addition, it was felt that the situation could have been avoided if interventions had been made earlier, as some of the issues were reported as being evident over the preceding 12 months. Some reported that they were potentially perceived to be complicit in the poor behaviours that had led to the suspension of training of foundation RDs. This reputational damage impacted the Trust, department and individuals, and it was felt that there could have been additional support and communication provided to individuals within the department following March 2024.

The period immediately after the suspension of foundation RDs from General Surgery was described as stressful, but there was recognition that the Trust had a good grasp of the issues and challenges to mitigate them on a sustainable basis. The review panel heard that staffing levels had been increased, with the role of MSWs seen as being particularly beneficial. It was encouraging to hear that the consultant body felt well supported by the Trust and that the OD initiatives to foster and promote a cohesive team were described as a positive team building exercise, despite initial perceptions that these were remedial or a ‘punishment’. However, it was saddening to hear that there was a reticence among some in the group to support foundation RDs in General Surgery in the event foundation training is reinstated in the department.

The review panel heard that the SoW duties were considered to be unfairly applied across the group, with some not taking on this responsibility. The review panel noted that consultants undertaking fewer clinical sessions at Barnet site were presumed to be exempt from the SoW arrangement. Likewise, the review panel advised that there were models for working across sites that could be explored within the Trust.

Areas that are working well

Areas for improvement

Immediate mandatory requirements

Action taken by the trust:

1. All doctors and the medical support workers in general surgery have been emailed with the name of the FTSUG and how to access the speaking up support offered (attached)

2. A summary of the FTSUG role and how to access speaking up pathways (attached) has been displayed in:

• surgical handover areas
• the doctors’ mess

3. The FTSUG attended the surgical consultants’ meeting on Friday 15 November to meet the team and to explain the role of the FTSUG and speaking up pathways

4. Arrangements have also been made for the FTSUG to attend the surgical clinical governance meeting on 4 December where most of the general surgeons will be present

5. The FTSUG and speaking up has been included in the faculty development programme in January 2025 to promote and sign post speaking up to the supervisor cohort

6. The FTSUG attended the Divisional Leadership meeting with the Nursing and Operational teams on Wednesday 6 November

Further action to be taken:

7. Escalating concerns is already included in the monthly resident doctors’ induction including information on the FTSUG and speaking up (slide attached).   We will work with the FTSUG to include speaking up presence at the monthly resident doctors’ inductions where possible

8. We will arrange a schedule of FTSUG/champion drop in’s at handovers/local faculty groups/departmental teaching sessions to continue to signpost the FTSUG and how to access the support offered and ensure that the attached speaking up leaflets are made available in these sessions

9. The speaking up team holds regular speaking up stalls at Barnet Hospital and we will also arrange a schedule of FTSUG/champion walk arounds to surgical wards and theatre areas

10. We will continue to include a joint GMC outreach and FTSUG led session on ‘raising concerns’ as part of the foundation year two generic skills programme and also explore additional sessions for other resident doctors.

11. Barnet Hospital business unit is developing a plan to raise the profile of speaking up to all staff groups across the site.  Additional Barnet Hospital site FTSU champions have been recruited to support this. 

Mandatory requirements

Recommendations

Report approval

Report completed by: John Marshall, Education Quality Manager, NHS England
Review lead: Prof Vivienne Curtis, System Dean – North Central London, NHS England
Date approved by review lead: 6 December 2024

NHS England authorised signature: Dr Elizabeth Carty, Interim Local Postgraduate Dean
Date authorised: 19 December 2024

Final report submitted to organisation: 19 December 2024

Publication reference: PRN01548