Executive summary

On the 5 and 6 of December 2024 a mixture of face to face and virtual review meetings were held with Maternity learners and educators at Cambridge University Hospitals NHS Foundation Trust (CUH), including higher, foundation, core, General Practice (GP), and International Medical Graduate (IMG) resident doctors in Obstetrics and Gynaecology (O&G), O&G trainers, Paediatric Neonatal resident doctors (across grades), and Midwifery learners and educators. The purpose of these meetings was to capture the learner and educator voice and their perspectives on the quality of the clinical learning environment in Maternity at CUH, as well as to review the impact of the open O&G improvement plan and evaluate the progress of improvements.

The report includes commendation for areas of good practice and educational requirements that need to be addressed through an improvement plan. NHS England Workforce, Training, and Education (WT&E) will review and update the open improvement plan to reflect feedback from these meetings.

The meetings demonstrated areas of good practice which include:

• The trust is engaged with NHS England WT&E Education Quality processes, and there was good attendance at all meetings apart from an anaesthetics meeting, where no residents attended. Following this non-attendance, anaesthetic resident feedback was sought via the CUH Anaesthetic Training Programme Director and College Tutor, with no significant concerns raised.
• All groups reported there are good learning opportunities and a good variety of cases.
• Interprofessional relationships were reported to be largely positive, with Multidisciplinary Team meetings (MDTs) praised by multiple learner groups and felt to be useful learning opportunities.
• O&G residents praised the introduction of a training week which supports their ability to attend clinics, go to theatre and focus on getting requirements signed off. WT&E note this is excellent practice and commend the trust for the introduction of the training week.
• Foundation/GP residents in O&G report the Obstetric team are supportive, and Obstetric consultants are happy to teach them. They also report registrars are helpful and provide good feedback.
• Paediatric Neonatal residents praised the quality of local teaching sessions, and felt they receive a good amount of teaching, they also reported they have good clinical support and can access support from paediatric neonatal consultants when required.
• Midwifery learners perceive the relationship between the midwifery practice educator (PEF) and Anglia Ruskin University (ARU) to be excellent with the PEF going to ARU to bridge the learning experience between placements and course work.

Feedback from the midwifery meetings highlighted a significant culture concern:

• Some Midwifery learners and educators reported the culture was toxic, with a perception from some that the department was not psychologically safe. Many learners felt they had experienced or witnessed bullying with educators also reporting they witnessed incivility in the unit. Both groups felt behaviours were sometimes related to protected characteristics and reported some areas ignore shift requirements and disability reasonable adjustment plans. Racism was also perceived to be evident in the department.  

The meetings also demonstrated other challenges in the clinical learning environment including:

• All resident and learner groups highlighted the Lady Mary ward (Post Natal ward) as a very challenging area, with O&G residents reporting limited in-person consultant availability despite scheduled daily 2 hours consultant coverage (attendance on the ward was reported to be consultant dependant with some coming, some not). O&G SHO residents expressed concerns they are often left with up to 30-40 patients under their care with limited consultant support.
• Paediatric Neonatal residents perceived the change in midwifery staffing which tasks multiple midwives with performing Newborn and Infant Physical Examinations (NIPEs), a change from a dedicated Lady Mary Ward NIPE midwife, impacts Neonatal SHOs as their time is taken up acting down and reviewing NIPE concerns such as reluctant feeders, this has a knock-on effect on residents’ ability to spend time on the Neonatal unit and indicates the tertiary placement is not being utilised efficiently for neonatal training.
• Paediatric Neonatal SHOs (Tier 1 residents) perceive their training is impacted by the requirement to take bloods (which in other units are taken by midwives and nurses), and they do not get sufficient time managing pre-term babies due to the number of blood tests they have to take for SBRs (a blood test to measure the level of bilirubin in a baby’s blood called serum bilirubin level (SBR)); they felt this can be a patient safety issue as this takes them away from the neonatal unit and there may not be enough support for high-dependency babies. Residents also reported the post-natal ward does not have the appropriate equipment to measure blood gases and SBRs and samples need to be sent to the lab. It was felt it would save time, alleviate workload and reduce the need to re-jab babies, if the blood gas equipment was available in the wards.
• Residents and Midwifery learners perceived silo working in wards and poor cross-ward working, with wards reported to use different guidelines for care (jaundice guidance was referenced) and a lack of joined up working which impacts safety and learner continuity. The Delivery Unit and Lady Mary Ward were highlighted as the most challenging wards.
• O&G and Paediatric Neonatal residents highlighted concerns about the volume of messages they receive via EPIC and noted the urgency of tasks is not clear without going through each message; residents struggle to prioritise tasks when they receive 50-60 messages at a time and felt this would be aided if messages could be risk rated or if midwives spoke directly to residents rather than texting at times (and then adding oral communication to the notes).
• Midwifery learners and educators report there are no appropriate drop-in spaces for confidential student conversations (though the trust confirmed rooms can be booked if required).
• Midwifery learners report they are sometimes left unsupervised, including situations beyond their scope of learning that were potentially unsafe. Additionally, they noted that without supervision they were not getting learning opportunities (and did not feel empowered to ask).

These areas need to be actioned and monitored against outcomes to ensure education quality improvements are embedded and sustained. NHS England WT&E will continue to work with CUH to agree milestones and actions against the educational requirements within the updated improvement plan.

Review overview

Background to the review

CUH has an active improvement plan in place for O&G and has been on the Education Quality Improvement Register (QIR) since July 2023 following concerns escalated by the School of General Practice to NHS England’s WT&E Quality Team, supported by deteriorating GMC NTS outcomes for F2 and GP programme residents in O&G, and with subsequent meetings in November 2023 that confirmed concerns for O&G residents. At the time of the 5^th & 6^th December 2024 meetings the QIR risk rating for CUH O&G was 12, Intensive Support Framework 2.

The purpose of this engagement was to triangulate the experience of all groups of Maternity residents/learners, to review the clinical learning environment and to gauge the success of the improvement strategies implemented in O&G to date, and to hear directly from residents/learners about their perceptions of the clinical learning environment and the support provided to them. The review meeting was conducted in accordance with the NHS England WT&E Education Quality Framework Domains and Standards for Quality Reviews and the report has been written in a manner that preserves the anonymity of residents/learners.

Evidence utilised

• NHS England WT&E internal governance documentation which includes feedback from improvement plan monitoring, and reports from previous engagement meetings
• GMC National Training Survey 2024 outcomes, National Education and Training Survey (NETS) 2023 outcomes, and partial NETS 2024 outcomes (survey closed shortly before engagement).
• CQC Inspection Report September 2023.
• 2024 Midwifery placement evaluation summary from Anglia Ruskin University.

Who we met with

Learners:

• O&G
• 7 foundation/core/GP residents
• 5 IMG residents
• 5 higher residents
• 5 IMG residents
• 5 higher residents
• 11 Paediatric Neonatal residents across grades
• 9 Midwifery learners across years, most in third year

Educators:

• O&G – 6 educators including the college tutor and divisional director
• Midwifery – 4 educators (practice educators and professional midwifery advocates)

Education team:

• Medical Director
• Director of Medical Education
• Deputy Director of Medical Education
• Head of Non-Medical Education

Review panel

• Education Quality Review Lead, Marjorie Casey, Education Quality Manager
• NHS England Education Quality Representative(s), Agnes Donoughue, Education Quality Coordinator

O&G meetings:

• Specialty Expert, Ms Erika Manzo, O&G Head of School.
• Specialty Expert, Dr Camila Tilbury, GP Training Programme Director.

Paediatric Neonatal meeting:

• Specialty Expert, Dr Vasanta Nanduri, Paediatric Head of School

Anaesthetic meeting:

• No attendees but support to access virtual feedback
• Specialty Expert, Dr Nina Walton, Anaesthetic Training Programme Director.

Midwifery Meetings:

• Specialty Expert, Kirsty Cater, Senior Nursing and Midwifery Clinical Lead.
• Specialty Expert, Cate Morgan, Senior Clinical Lead (Nursing and Midwifery), WT&E

Review findings

Learning environment and culture

All groups reported there are good learning opportunities in Maternity services at CUH with good exposure to a wide variety of cases, and all resident and learner groups felt supported by their educators. O&G residents reported the culture is good and there is good multidisciplinary working with most colleagues supportive and approachable, though higher residents perceived communication across the division was challenged with limited communication between Obstetrics and Gynaecology consultants. Foundation and GP O&G residents perceived obstetric consultants are supportive and enthusiastic about teaching, and there is good exposure to complex patients. Gynae consultants were also reported to be good, though foundation/GP O&G residents reported they do not see this group of consultants as often. O&G residents report there have been improvements in the culture with consultants supportive of them and stepping down to help when required. The introduction of regular meetings with the Doctors for Doctors charity was felt to have had a positive impact on working culture and relationships between consultants and trainees.

Interprofessional relationships were reported to be largely positive, with multidisciplinary team meetings (MDTs) praised by multiple training/learner groups and felt to be useful learning opportunities. However, Paediatric Neonatal residents report multiprofessional working is variable, with good team working for elective procedures, but some challenges and incivility reported when it is busy (RQ1). Midwifery learners had variable experiences of the culture with many learners feeling welcome and others reporting the culture is toxic. While all midwifery learners reported feeling well supported by practice educators and the professional midwifery advocates (PMA), learners perceived some groups of midwives were not welcoming, with some feeling the environment was not psychologically safe due to perceived blame shifting and a culture of openly talking about other colleagues in their absence. Some learners also reported feeling there was racism in the department and sensed divides between international graduates and some white British midwives. Midwifery educators agreed the culture of supporting learners is challenged with some ward areas not as accommodating of learner requirements, including those relating to protected characteristics (i.e. reasonable adjustment) (RQ1).

All resident and learner groups noted Lady Mary Ward (the postnatal unit) was a very challenging area. O&G residents reported a consultant is allocated to the ward 2 hours a day however, the scheduled consultant will frequently be in planned clinics or on call and not accessible to resident doctors (RQ2). O&G SHO residents expressed concerns they are often left with up to 30-40 patients under their care and limited in-person consultant support (RQ2). One consultant was felt to be exceptional in her attendance on Lady Mary Ward (LMW) and works to review patients with residents. Other consultants were noted to have very good care plans, which residents find very helpful, but there were also reports of patients on LMW who were not reviewed by a consultant for up to 7 days, which was felt to be unsafe. It was felt that daily consultant or senior review of patients is necessary, however getting someone senior to review a patient in person can be very difficult (RQ2).

O&G and Paediatric Neonatal residents felt that midwives on LMW, themselves were under pressure to get patients reviewed, apply pressure to residents to sign off patients which can be challenging as some patients need a senior medical review; residents reported there have been times when they found a patient who was very unwell but had not yet been escalated. Neonatal Residents did not feel there was a system or clear criteria in place that provides guidance about which patients should be escalated, and to which specialty. It was felt a checklist for who/how to escalate and to what areas was needed (RC1). O&G residents suggested a morning review undertaken with a senior resident or consultant would be very useful (RQ2). Adding to this pressure, O&G residents are sometimes asked to cross cover between LMW and the gynaecology ward (Daphne Ward) which they reported can be overwhelming, feel unsafe, and does not allow them time to take any breaks. Furthermore, they described pressure to complete discharge summaries which are less clinically urgent, but impact bed availability and morale. O&G Residents felt there have been improvements in the number of SHOs over the past year (there are now 2 instead of 1) but noted it is still very busy. It was noted that though resilience in the system has improved, workload may still be impacted by sickness or leave.

This was also highlighted by O&G trainers, who reported they are collectively committed to maintaining and protecting the 1:10 rota, backed up by medical staffing, even though it was acknowledged this puts pressure on consultants to act down when there are gaps in the rota that cannot be filled by agency or locums. It was reported that despite increasing staffing, rota gaps due to residents being out of programme are challenging to fill, and the department does not operate at full capacity. On call at night has improved with better cover due to the addition of a fourth doctor, leading to improved safety. However, it is still very busy, and it was strongly felt that a 5^th doctor at night would provide better supervision, enhance patient safety and have a positive impact on the residents’ day experience (RC2).

Both O&G and Neonatal residents reported EPIC messaging could feel unmanageable, with residents reporting if they have been in theatre they may come out to 70 messages waiting for them with no way to identify which messages are urgent and unable to gauge the urgency of a request via chat (RC3). Neonatal residents felt messaging is used when a conversation would at times be better. As messaging does not clarify the urgency or the area required, it can lead to delays in baby’s treatment (example provided of surgical problem that was ambiguous and not addressed to the correct team). Neonatal residents also reported challenges with alerts for crash calls as they are unable to differentiate between a call for neonatal or obstetrics (it is the same call for a C section and a post-partum haemorrhage) and when they respond they may find they are not needed (this was felt to be an issue for anaesthetics as well) (RC3).

Paediatric Neonatal residents reported an understaffing of nursery nurses on LMW has an impact on training as resident doctors are required to step down to do simple bloods or blood gases which could be completed by a nurse. On a night shift residents may spend most of their time doing SBRs, which impacts training because they do not get time managing pre-term babies (RQ3). This impacts training experiences and was also reported to be a potential patient safety issue as there is not sufficient support for high-dependency babies (only 2 doctors managing 40 babies at night). Paediatric Neonatal residents perceived the change in midwifery staffing, which tasks multiple midwives with performing NIPEs (a change from a dedicated Lady Mary ward NIPE midwife), impacts Neonatal SHOs as their time is taken up reviewing NIPE concerns such as small pupils and reluctant feeders (the feeding team are available Monday to Friday 7:30 to 17:00, but not out of hours), this has a knock-on effect on residents’ ability to attend teaching and indicates the tertiary placement is not being utilised efficiently for neonatal training. Residents reported the ward does not have the equipment to analyse SBRs and samples must be sent to the lab, and felt if equipment was available on the ward, this could be done as Point of Care testing saving time and alleviate workload (RC4). Moreover, LMW was reported to not follow NICE guidelines (RQ4), with babies requiring multiple pricks for tests, sometimes several times a night to get an accurate sample as tests need to be repeated (RC4). Midwifery learners also highlighted appropriate equipment (stethoscopes) not always being available on LMW (RC4).

Neonatal residents and midwifery learners both reported poor cross ward collaboration. Paediatric Neonatal residents perceived handover across wards is sometimes challenged and procedures that should have started are delayed in the transfer (for example prescribing antibiotics is deferred until the baby is transferred when it should have been prescribed and administered urgently). Another example of poor cross ward working related to jaundice guidelines, which were reported to vary across wards and not matching the NICE guidelines (RQ4). Midwifery learners and educators also highlighted silo ward working as challenging and felt learner opportunities were not consistent across wards. Some midwifery learners described incidences where midwives across wards appeared to not work well together with a blame culture at times (RQ1). The delivery unit and the birth areas were felt to be particularly divided.

Midwifery learners and educators reported a lack of appropriate facilities for providing support, with no space for teaching and no facilities for confidential student conversations (RQ5)

Educational Governance and Commitment to Quality

While midwifery learners felt supported by Practice Educators, educators did not feel valued by the trust or division. Within the division, there are two people who manage the support of approximately 100 midwifery students with reports of unpaid work required to stay on top of the administration of the role while also supporting learners. Practice educators are sometimes required to work clinically to backfill but noted the education role was not back filled. It was reported there is a communication gap between escalation of issues to divisional senior management and feedback and next steps to trainees. It was recognised by the attendees that successful cultural change needs to come from the top down, feedback on outcomes of escalations would support this. (RQ1).  

Developing and Supporting Learners

O&G Foundation and GP residents report feeling supported and able to access senior support in most areas apart from the postnatal ward/Lady Mary ward which is SHO driven and reported by all resident and learner groups to be a very challenging area (RQ2).

O&G residents and IMGs praised the introduction of the training weeks (one week in every 14 weeks) when they can go to clinics, theatre and work to get their competencies signed off. Residents felt these were very helpful but thought the expectations for the training week could be set out more clearly at induction to better enable them to plan so they are able to get the most out of the week. They felt it would be helpful to have a list of the clinics available, with the contact details of doctors so they can organise attendance (RC5).

Paediatric Neonatal residents praised the quality of local teaching sessions, and felt they receive a good amount of teaching. Neonatal residents reported they have good clinical support and can access support from paediatric neonatal consultants when required.

Midwifery learners felt very supported by the practice educators and professional midwifery advocate and noted the relationship between the PEF and Anglia Ruskin University (ARU) to be excellent with the PEF going to ARU to bridge the learning experience between placements and course work. However, many learners provided examples of instances they were pulled into service demand and used to do things that midwifery support workers would do, particularly in the high-risk unit, and on nights. They thought this interferes with educational opportunities because they are doing unsupervised observations or making beds instead of shadowing a midwife and receiving necessary learning opportunities. It was reported that learners are sometimes left unsupervised, occasionally in situations that were beyond their scope of learning and potentially unsafe (RQ7).  Learners shared they are sometimes given easier jobs because the midwife they have been paired with does not want to teach or explain what they are doing or does not want to do the jobs themselves.

Developing and Supporting Supervisors

O&G trainers report they feel valued by the trust and trust management has been supportive of the changes initiated in the department to improve the experience for residents.

Midwifery educators felt midwives needed more support for the educator role and noted the training to qualify to be a practice supervisor (presently 1 hour a year training) is set to be reduced to 30 minutes per year due to other training requirements for midwives. The preparation for practice assessors and practice supervisor training was reported to have not been taking place, with practice assessor numbers reduced as a consequence. Funding had been requested for training (allocated Professional Midwifery Advocate service) but has not yet been located, however the Head of Non-Medical education clarified in the higher feedback session that Practice Assessor training had just been relaunched.  (RC6)

Delivering Curricula and Assessments

Both O&G residents and trainers noted an intention to deliver once a month 4-hour teaching sessions was challenged by service pressures. Both groups reported recently one-hour weekly teaching sessions are more achievable, with residents reporting they would welcome further training, particularly a morning or lunchtime session led by consultants to share their expertise on topics (RC7). Higher O&G residents report nurses run 2-week clinics which residents can attend and where they can see ‘the basics’ which they do not see in consultant clinics which are typically more specialist cases. O&G residents reported the rota being managed by an administrator with limited or no knowledge of their curricula was not conducive in supporting their learning needs without adequate medical oversight. Good practice was noted in some groups where residents have taken the initiative to work collaboratively in providing the oversight needed to ensure their training needs are being addressed. 

Areas that are working well

Good practice

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Marjorie Casey, Education Quality Manager
Review Lead: Tracy Wray, Regional Lead for Education Quality
Date signed: 24 January 2025

NHS England authorised signature: Professor Bill Irish, Regional Multi-professional Dean and Postgraduate Dean
Date signed: 28 January 2025

Final report submitted to organisation: 6 March 2025