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Executive summary
The review panel thanked the trust for accommodating this quality review and for facilitating good attendance on the day. After discussions with the Trust’s educational leadership team, the review panel identified some key areas for improvement and some areas that were working well within the Trust.
It was clear to the panel that the trust were aware of the issues and that they had devised plans to improve the training experience of resident doctors in general surgical higher specialty training and core surgical training at the Royal London Hospital. It was also encouraging to hear that resident doctors were able to access high volumes of endoscopy training whilst placed at the site.
However, the panel identified the following areas for improvement:
- attendance of resident doctors at local teaching
- attendance of resident doctors at local faculty group meetings
- timetabled access to operative experience for core surgical training resident doctors
- communication channels between educational leads within surgery
The panel assigned provisional Intensive Support Framework (ISF) ratings for the programmes as following:
- General Surgery higher specialty training: ISF 1 (new rating)
- Core Surgical Training: ISF 2 (unchanged)
NHS England’s Education Quality team will monitor the sustainability of these improvements via the Mandatory Requirements on the Quality Management Portal (QMP) which can be found towards the end of this report.
Review overview
Background to the review
This Senior Leader Engagement Visit was initiated in response to negatively outlying 2024 General Medical Council (GMC) National Training Survey (NTS) results for general surgery specialty training at The Royal London Hospital. The Trust’s self-report on these results in September 2024, submitted by the Postgraduate Medical Education team, advised that there was limited engagement with the process, or the survey results, from within the department.
It was agreed with the Trust that NHS England – London would conduct a Senior Leader Engagement Visit in early February 2025 to discuss the 2024 NTS results and educational and clinical leadership of the general surgery department and determine whether any actions were required to assure the quality of the general surgery learning environment for core and specialty level resident doctors in training. Core surgical training across all specialties was incorporated into discussions.
The Trust provided the following evidence in preparation for this review:
- General Surgery Higher Specialty Training (HST) Trainers
- General Surgery Foundation Year 1 (F1) Trainers
- List of learner groups
- Exception Report Data December 2024
- Surgery Teaching Programme January 2025
- Barts Freedom to Speak Up (FTSU) Board Report 2023-2024
- Barts FTSU Case Escalations, Outcomes and Actions – September 2024
- Core Surgical Training (CST) Local Faculty Group (LFG) Minutes 13-11-2024
- Medical Education Committee (MEC) minutes 22-05-2024
- MEC minutes 21-08-2024
- MEC minutes 11-12-2024
- Datix Report – General Surgery
- General Surgery Rota October 2022-2023
- Work Schedules – Colorectal Master Rota
- SACIndicative_7754001
- Core Training Year 1 (CT1) Logbook Email
- CT1 Logbook Upper Gastrointestinal (UGI) Surgery
- HST Logbook General Surgery
Who we met with
Education team:
- Two Directors of Medical Education
- Associate Director of Medical Education
- Clinical Director of the Surgical Division
- Medical Director, Royal London Hospital
- Clinical Governance Lead
- Trust Dean
- Two Education Leads for General Surgery
- Royal College of Surgeons (RCS) College Tutor for Trauma and Orthopaedic Surgery
- Divisional / General Manager
- Lead for Postgraduate Medical and Dental Education
- Two Medical Education Managers
Review panel
- Dr Louise Schofield, System Dean – North East London, Education Quality Review Lead. NHS England – London
- Mr Dominic Nielson, Deputy Head of the London Specialty School of Surgery, Specialty Expert. NHS England – London
- Mr Paul Ziprin, Consultant General Surgeon, External Specialty Expert. Imperial College Healthcare NHS Trust
- Nicole Lallaway, Education Quality Coordinator. NHS England – London
Review findings
Trust presentation
The trust delivered a presentation to the NHS England – London review panel, detailing an overview of the surgical division within The Royal London Hospital and the educational leadership for the general surgery and core surgical training (CST) programmes. The panel heard that the surgery division comprised of general surgery, gynae oncology Surgery (GyO), vascular surgery, urology and ear, nose and throat (ENT) surgery, and that the subspecialties of colorectal, hepato-biliary (HPB) surgery and upper gastrointestinal (UGI) surgery fell under general surgery. It was also reported that some of the surgical specialties did not fall under the surgical division, for example the trauma and orthopaedic (T&O) surgery and plastic surgery specialties fell within the emergency care and trauma division, of which comprised a significant part of core surgical training for CST resident doctors (RDs). It was felt that this added some difficulty for the Trust when trying to understand the training issues for CST RDs. The CST surgical tutor was also reported to be on leave of absence for approximately the next 12 months. The Trust reported that it had three trust-wide Royal College of Surgeons (RCS) college tutors, one for ENT, one for orthopaedics and one for colorectal, and that it recognised that these roles would benefit from being a site-specific tutor role and would report to the Director of Medical Education to provide consistent support for the CST RDs.
Educational Leadership
The Trust indicated that the surgical division had recruited two new education leads for general surgery, a governance lead, and a clinical educator, and one of the new consultants had dedicated Supporting Professional Activities (SPA) time in their job plan to support and manage the CST RDs. The Trust felt it was in a more secure position to focus on the delivery of education due to some of these changes in the educational leadership structure.
The panel heard that the surgical division was deeply affected by the unfortunate death of its education lead in 2023, who led on the education programmes, the recruitment of RDs and RD welfare. The Trust discovered that the educational contribution of the previous education lead was not included in the department’s budget nor was it job planned for. However, after working for a period of time, the two new educational leads for general surgery were appropriately job planned and renumerated for their educational contribution.
It was reported that the Trust felt there needed to be an improved overview of CST within The Royal London Hospital, and that it required a stronger focus on education and leadership. The panel heard that the orthopaedics RCS college tutor was working closer with the leadership team, and that local faculty group (LFG) meetings were put in place for CST RDs to provide feedback on their training.
With the recruitment of many different educational roles within the surgical division, the panel felt that the Trust would benefit from arranging regular communication channels between the extended surgical educational faculty to ensure robust processes were in place and remove the risk of duplication. In addition, the panel felt that individuals involved in the education and training of RDs would benefit from attending annual competency and progression reviews (ARCPs) to better understand the educational requirements and curriculum for RDs in training.
Rota and rota gaps
Improvements had been made to support the development of the rotas, including the recruitment of a rota coordinator and general manager. However, it was acknowledged that gaps in the rota among the RD cohort and the consultant group may have had a negative impact on training. The Trust reported that there were multiple gaps on the consultant rota for general surgery and colorectal surgery, and that gaps were cross covered by senior fellows, a locum doctor and the recruitment of two new colorectal consultants in December 2024 and January 2025. The panel heard that there were still two gaps on the consultant rota and that business cases were in place to recruit additional consultants. In addition, gaps on the RD rota, including unfilled posts and less than full time (LTFT) working, may have impacted on RD access to elective operative experience.
Local teaching
The panel heard that the two education leads for general surgery came into post approximately two years ago, and that they established a weekly teaching programme with a focus on higher specialty surgical RDs. However, it was reported that attendance at the local teaching sessions was variable with poor uptake amongst the general surgery RDs.
Adequate experience
The panel heard that general surgery RDs were offered a logbook review three weeks prior to beginning their placement to better plan experience required whilst training at The Royal London Hospital. However, it was reported that some RDs were reluctant to show their logbooks and engage in planning when beginning their placement. In addition, RDs were assigned an educational supervisor when they began their placement, and it was reported they met with the educational leads approximately 4-6 months into their placement to review their logbook and identify if RDs needed to move their rotation around to get adequate experience.
The panel heard that CST RDs in T&O had protected time for two sessions per week of theatres and clinics, and CST RDs in plastic surgery had protected time for 2-3 sessions in theatre and 1-2 clinics per week. However, whilst this time was reported as protected, it was not explicitly timetabled in the rota for CST RDs which meant that RDs may not get adequate access to operative experience, particularly for T&O CST RDs.
However, the panel was pleased to hear that general surgery RDs were able to access high volumes of endoscopy training whilst training at The Royal London Hospital. It was felt that this was positively impacted by some of the educational leads working closely on endoscopies and encouraging this piece of work.
Local Faculty Groups
The panel heard that LFG meetings had poor attendance by RDs, and it was felt this was impacted by other commitments required of RDs. The panel heard that LFGs were often scheduled on audit days, with the aim to get as many RDs as possible in a physical room. It was acknowledged that this was a work in progress, and it was clear to the panel that work needed to be undertaken to develop robust LFGs for RDs to provide meaningful feedback, including some consideration as to why RDs were not attending the meetings.
The panel also heard that the education leads felt they were approachable to RDs, by being a visible presence on the wards, having an open-door policy and offering formal or informal 1:1 meetings to RDs.
Areas that are working well
| Description | Reference number and/or domain(s) and standard(s) |
|---|---|
| It was clear to the panel that the Trust were aware of the issues and that they had devised plans to improve the training experience. | GS2.6 and CST2.6 |
| The panel was pleased to hear that resident doctors were able to access high volumes of endoscopy training. | GS5.1 and CST5.1 |
Areas for improvement
Mandatory requirements
| Review findings | Required action | Reference number and/or domain(s) and standard(s) |
|---|---|---|
| With the recruitment of many different educational roles within the surgical division, the panel felt that the Trust would benefit from arranging regular communication channels between the extended surgical educational faculty to ensure robust processes were in place and remove the risk of duplication. | The Trust is required to devise a regular form of communication between the various educational leads within the surgical division, for example a regular surgical educational meeting. Please submit an update to this piece of work on the Quality Management Portal (QMP) by 1 June 2025. | GS1.1a and CST1.1a |
| The surgical division would benefit from those in educational roles attending annual competency and progression reviews (ARCPs). | The Trust is required to facilitate the attendance of RCS College Tutors to ARCPs and should encourage educational supervisors to attend ARCPs where possible. Please submit progress against this action on QMP by 1 June 2025. | GS4.5 and CST4.5 |
| The panel heard that despite devising a local teaching programme, attendance at the local teaching sessions had poor uptake among RDs. | The Trust is required to review the teaching programme for general surgery higher specialty RDs and core surgical training RDs, to better understand why RDs are not attending local teaching sessions. The Trust is also required to devise a plan to address this issue. Once this work is undertaken, NHS England requires demonstrable RD feedback that they can attend local teaching sessions. Please submit progress against this action on QMP by 1 June 2025. | GS5.6 and CST5.6 |
| Whilst it was deemed protected time, operative experience was not timetabled in the rota for CST RDs. | The Trust is required to develop a robust plan for the timetabling of operative experience for CST RDs that ensures access to the curriculum requirements and experience necessary for career progression. Please submit progress against this action on QMP by 1 June 2025. | CST5.1 |
| The panel heard that local faculty group (LFG) meetings had poor attendance by resident doctors, often due to other commitments. | The Trust is required to undertake work to develop robust LFGs for RDs to provide meaningful feedback, including some consideration as to why resident doctors were not attending the meetings. Please submit progress against this action on QMP by 1 June 2025. | GS1.1b and CST1.1b |
Report approval
Report completed by: Nicole Lallaway, Education Quality Coordinator, NHS England – London
Review lead: Dr Louise Schofield, System Dean – North East London, NHS England – London
Date approved by review lead: 19 February 2025
NHS England authorised signature: Elizabeth Carty, Interim Local Postgraduate Dean, NHS England- London
Date authorised: 10 March 2025
Final report submitted to organisation: 14 March 2025