Executive summary

The review panel was thankful to the Placement Provider (PP) for accommodating this review and for facilitating good attendance. The review panel was pleased to hear that the Resident Doctors (RDs) had noticed improvement in issues that had been raised previously. RDs were aware that the department had been working hard to make improvements and commended the efforts of the College Tutor, Training Programme Director, and Clinical Director to make improvements to training. RDs noted that they felt supported by the educational leadership in the department.

The review panel was also pleased to hear that there was a wide variety and high volume of teaching available to RDs. RDs were particularly complimentary of the efforts of the Teaching Lead consultant and were appreciative of the enthusiasm that the consultant body had for teaching.

RDs reported that clinical supervision, both in and out of hours had significantly improved and noted that remote consultant supervision was not a frequent occurrence. However, the review panel noted concerns that Specialty Training Year 3 (ST3) RDs were running ultrasound lists without direct supervision to cover consultant leave. RDs reported that there was a named consultant who could be contacted in this circumstance, however RDs advised that the lack of direct supervision limited the educational value of the work.

RDs reported significant issues with on-call rota gaps and rota gaps at the RD level more generally. RDs informed the review panel that there were long-term rota gaps at the Royal London Hospital (RLH) site which had impacted access to sub-specialty experience and limited the flexibility in the rota. The review panel was also informed that high volumes of phone calls at the weekend from elective outpatient clinics and diagnostic hubs was increasing the workload of weekend shifts, which were reportedly the busiest shift already.

NHS England-London’s System Dean for North East London and Head of the London Specialty School of Clinical Radiology will explore the issues raised regarding post allocation between the different sites at the PP. NHS England’s Intensive Support Framework (ISF) rating of Clinical Radiology at the RLH has been reduced to ISF 1. This report includes specific requirements for the PP to take forward, which will be reviewed by NHS England- London as part of the three-monthly action planning timeline.

Review overview

Background to the review

This Learner Review was initiated in response to negatively outlying 2024 General Medical Council (GMC) National Training Survey (NTS) results for clinical radiology specialty training at Royal London Hospital (RLH).

The Placement Provider’s (PP) self-report on these results in September 2024 confirmed that they were expected and reflected multiple factors contributing to learner dissatisfaction, mainly around an increasing on-call workload and perceived changes in daytime consultant supervision. Around the time the 2024 NTS was launched, the specialty already had nine outstanding open actions on NHS England – London’s Quality Management Portal relating to the Learner and Educator Review conducted in January 2023.

Whilst the PP’s self-report was comprehensive and set out a number of appropriate and relevant actions to address the issues identified, NHS England – London required further assurance that they are sustainable and will deliver the training experience hoped for. As such, the aim of this Learner Review was to meet with resident doctors in training to ascertain detailed feedback on sustainability.

The content of the review report and its conclusions are based solely on feedback received from review attendees. The following evidence provided by the PP was used by the review panel to formulate the key lines of enquiry for the review:

• Internal Action Plan – Clinical Radiology
• Breakdown of Learner Groups and Educational & Clinical Supervisors
• Exception Report Data December 2024
• List of Clinical Radiology Audit Meetings
• Teaching feedback August 2024- January 2025
• Teaching Rota- November 2024- February 2025
• Freedom to Speak Up Guardian Board Reports 2023-2024
• Specialty Training (ST) Year 1 Induction Feedback – August 2024
• Local Faculty Group (LFG) Meeting Minutes- March 2024, May 2024 and November 2024.
• Medical Education Committee (MEC) Meeting Minutes- May 2024, August 2024 and December 2024
• Datix Report – Clinical Radiology
• Rota information
• Work Schedules for all ST levels

Who we met with

Learners

• 18 Resident Doctors in Clinical Radiology Specialty Higher Training

Review panel

• System Dean- North East London NHS England- London, Louise Schofield Education Quality Review Lead
• Head of the London Specialty School of Clinical Radiology, Samantha Chippington NHS England – London Specialty School of Clinical Radiology Representative
• Training Programme Director NHS England- London, Samir Alwan External Specialty Expert
• Saira Tamboo Lay Representative
• Education Quality Coordinator NHS England- London, Rebecca Bennett Education Quality Representative
• Education Quality Coordinator NHS England- London, Sahariyea Siddique Education Quality Representative (Observing for training)
• Education Quality Coordinator NHS England- London, Lauren Thomson Education Quality Representative (Observing for training)   

Review findings

Culture

Resident Doctors (RDs) were complimentary of the culture in the department. RDs reported that there was a flat hierarchy in the department, and they felt comfortable approaching consultants. RDs also noted that they were actively encouraged to give honest feedback. RDs informed the review panel that consultants in the department had been very supportive and were understanding of Less Than Full Time (LTFT) Training, illness and other personal circumstances. However, due to rota pressures, there was less support for RD’s to apply for LTFT or take time out of training.

RDs informed the review panel that the department frequently experienced inappropriate communication in phone calls from other departments when discussing referrals. It was reported that the calls came from a wide variety of departments, but some were more likely than others. RDs advised that there were often disagreements about the urgency of scans and RDs felt that there were discrepancies in the expectations of the radiology department. RDs acknowledged that they often felt unable to challenge referrals without conflict from the referring team and that the referring team were unresponsive to compromises. RDs informed the review panel that there had been instances where incorrect information had been provided in referrals to increase the likelihood of the referral being accepted. RDs confirmed they felt comfortable to discuss this issue with the consultants in the department but advised that they often did not as the consultants were limited in what they could do to resolve the issue. RDs reported that they would appreciate more support from the radiology consultants when other departments raised issues about referrals.

Educational governance and raising concerns

Some RDs reported that they had noticed the amount of work that the department had been doing to make improvements to the training experience and that consultants had been responsive to making improvements. RDs reported that the clinical and educational leadership in the department had improved and RDs were very complimentary of the Clinical Director, College Tutor and Training Programme Director.

RDs advised that they were aware of the different avenues for reporting concerns and felt comfortable approaching the Clinical Director, College Tutor and Educational Supervisors to raise concerns. RDs felt comfortable approaching any consultant in the department with feedback and felt they would be receptive. However, RDs reported that whilst the department was receptive to feedback, they felt that issues involving the wider hospital system were slow to progress.

Clinical supervision

The review panel was informed that clinical supervision had significantly improved. RDs confirmed that it was rare to be supervised by a consultant working from home during the day. The review panel enquired about access to sub-specialty clinical supervision and the RDs reported that generally there were no concerns with this but noted that there was not always a consultant available for nuclear medicine.

RDs reported that consultant presence for Acute Computerised Tomography (CT) and ultrasound sessions had improved. RDs felt there was more transparency in the rota and noted that gaps in consultant availability were highlighted in advance. RDs confirmed that outpatient clinics and fluoroscopy lists were cancelled when consultants were on leave. However, it was reported that for ultrasound lists there was no cover for consultant leave therefore the Specialty Training Year 3 (ST3) RDs ran the list unsupervised. RDs added that the patient numbers were reduced on an unsupervised list but noted the workload was still busy. RDs clarified that recently the department had introduced a named consultant contact for the unsupervised lists, which RDs felt was an improvement, however, RDs felt that the lack of direct supervision significantly limited the educational value of the work.

RDs reported that ST2 RDs were disproportionately allocated to cover the mobile ultrasound rota, which limited their access to other education opportunities. RDs also felt that without access to feedback from direct supervision there was also little educational benefit from the work.

RDs confirmed that they could always access support and advice from consultants out of hours. However, some RDs reported that there had been some instances where the switchboard did not have the correct contact number for the consultant on-call. The review panel was informed that this issue had been raised with the department and the consultants had been reminded that they must update switchboard when shift swaps resulted in changes to contact information.

Workload

RDs reported that it continued to be challenging to get peripheral vascular and aortic CT angiograms signed off. RDs felt there was no clear pathway or clarity on responsibilities for these scans and noted that it required significant chasing to obtain sign-off. RD noted that this issue had been raised repeatedly but no improvements had been made.

RDs discussed the workload on-call and advised that the on-call complexity and intensity was challenging but many described this as good exposure for training. RDs reported that when there was only one RD on the on-call rota due to gaps the workload was very high, even with additional outsourcing which was approved by the consultant. RDs explained that it also made the on-call more unpredictable and as a result some RDs described instances where they had not been able to take breaks. RD also reported that the workload was not scaled back when the on-call was short staffed, for example not pushing back on non-urgent Magnetic resonance imaging (MRI) requests. RDs informed the review panel that often MRIs which had been requested during the day were having to be completed at night as there had been issues with portering during the day. The review panel was also informed that there was additional workload out of hours from offsite diagnostic hubs and elective outpatient clinics. RDs advised that there were a significant number of phone calls from the hubs and outpatient clinics which they felt pressure to answer.

RDs advised that weekend daytime shifts were the busiest and many RDs were apprehensive about these shifts. RDs informed the review panel that recent changes to access to outsourcing had made improvements to their experience. It was advised that up to 5 scans in a 24-hour period could be outsourced which were usually used for the night shift, and this increased to up to 10 scans in 24 hours at the weekend. However, RDs acknowledged that there were restrictions to the type of scans which could be outsourced and advised that most of the ones that could be sent had the most educational value.

Rotas

RDs reported that there was a significant issue with the number of RDs on the rota at the Royal London Hospital (RLH) site. The review panel was informed that there was also a significant number of long-term gaps on the rota, particularly senior RD posts. RDs felt that issues with staffing was a relatively new issue but noted that it was getting worse. It was reported that the shortage of RDs limited the flexibility in the rota which prevented easy access to the spread of experiences required to meet curriculum requirements, particularly access to sub-specialty experiences. It was noted that the lack of flexibility in the rota also made it difficult to fill short term gaps caused by annual leave and sick leave. RDs explained that the department was constantly chasing for help to fill the rota gaps which was sometimes a source of tension. RDs informed the review panel that covering on-call gaps reduced the time spent in their sup-specialty which was sometimes commented on by the sub-specialty consultants. RDs advised that this had caused them to be a lot more protective of their sub-specialty time and therefore they were more reluctant to volunteer to cover rota gaps.

RDs perceive that a disproportionate number of posts sit at one of the PP district general hospital sites. At this site, the service is consultant delivered and RDs feel that the distribution of posts is negatively impacting the rotas at the busier RLH site. RDs believed that the posts would be better allocated to the RLH site which relied upon the RDs more for service provision.

Teaching and curriculum coverage

Many of the RDs reported that the variety of cases at the RLH was very good and there was a wide variety of teaching available in the department. RDs were particularly complimentary of the efforts of the Teaching Lead consultant and RDs noted that there was a lot of enthusiasm from the consultant body to do teaching. RDs also reported that they were planning to give various teaching awards to the consultants to show their appreciation for their efforts.

RDs acknowledged that RD attendance at teaching was low and confirmed this was not the fault of the department. RDs advised the review panel that they were looking at improving engagement with teaching as a learner group.

RDs informed the review panel that there had not been any issues with access to regional teaching or study leave. RDs advised that there had been issues with access to paediatrics teaching but noted that there were plans to improve this.

Areas that are working well

Areas for improvement

Immediate mandatory requirements

• Not applicable

Mandatory requirements

Recommendations

Report approval

Report completed by: Rebecca Bennett, Education Quality Coordinator, NHS England-London
Review lead: Louise Schofield, System Dean North East London, NHS England- London 
Date approved by review lead: 8 April 2025

NHS England authorised signature: Elizabeth Carty, Postgraduate Dean, NHS England- London
Date authorised: 28 April 2025

Final report submitted to organisation: 28 April 2025