Executive summary

On 7 November 2024 face to face meetings were held with East Suffolk and North Essex NHS Foundation Trust (ESNEFT), Ipswich Hospital, residents and trainers in Surgery posts (including higher, foundation, core and GP programmes) to review the impact of the open improvement plan and to evaluate the progress of improvements.

This report has been written in a manner that preserves the anonymity of residents and includes commendations for areas of good practice as well as educational requirements that need to be addressed. 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 all meetings were well organised and well attended.
• The facilities for residents were praised, especially the rest facilities which were reported to be easy to book.
• All residents reported they could access study and annual leave.
• The General Surgery rota coordinator was praised by both residents and trainers. Trauma and Orthopaedic (T&O) foundation residents also felt their rota was well managed.
• Regular training is organised for General Surgery and T&O.
• Residents reported consultants were generally friendly and supportive, and foundation/core residents felt registrars are also supportive.
• One ortho-geriatrician (medicine) consultant was deemed to be very supportive of foundation residents and praised for providing an excellent training experience through their efforts to ensure residents understand patient plans and discharge planning as well as providing cross ward support to residents on an ad hoc basis.

However, there are still areas of concern that need to be addressed, including two potential patient and resident safety risks identified which required an immediate 5-day response:

• General Surgery and T&O residents provided multiple examples of the Emergency Department (ED) ‘fit to proceed’ policy enabling the ED to refer patients to the surgery division without appropriate investigations or notice, including a patient with an ectopic pregnancy, and another patient with an ischemic limb, both of which once referred, required significant work to turn around to the appropriate division with time lags that were perceived as potentially dangerous. Interpersonal relationships with the ED were perceived to be challenging, with rudeness reported to be common and ED colleagues felt to be unwilling to engage when referrals are questioned.
• Overnight staffing in general surgery was reported to be insufficient at times, with occasions reported of large numbers of patients being looked after by one relatively junior resident doctor. This was exacerbated by the requirement that residents escort patients to CT scans, potentially taking one resident away from the wards for most of the shift.

The trust provided responses to the immediate concerns; however, further clarification is being sought by NHS England WT&E regarding the concerns which will be followed up outside of this report. This will enable the report to be shared, and responses and plans put in place to support with improvements and actions identified in the report.

The meeting feedback demonstrated a number of challenges to the learning environment, many of which are longstanding and identified as actions within the previous improvement plan indicating a revised approach may be required to ensure improvements in these areas are embedded and sustained:

• All groups of residents reported occasional belittling and incivility both within the department and from external colleagues.
• Residents reported they did not exception report. Foundation residents stated that processes take too much time, and they lack belief that anything would change if they exception report. Higher residents were also not exception reporting due to a perception that educational supervisors view exception reports as a negative reflection on themselves. 
• Higher residents felt induction was insufficient with no contact numbers provided and many reporting they did not receive appropriate log-ons and/or access to systems before starting shifts, some of which were still unresolved weeks after starting.
• Higher residents felt the case mix and surgery numbers are not sufficient to meet their curriculum requirements and expressed concerns about their ability to achieve their targets this year.

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 ESNEFT to agree milestones and actions against the educational requirements within the updated improvement plan.

Review overview

Background to the review

The review meeting was implemented following existing concerns for the clinical learning environment within Surgery at Ipswich Hospital, to review the clinical learning environment, and to gauge the success of improvement strategies implemented to date. The review meeting has been conducted in accordance with the NHS England WT&E Education Quality Framework Domains and Standards for Quality Reviews.

ESNEFT Ipswich Hospital has an active improvement plan in place for foundation surgery and has been on the Education Quality Improvement Register (QIR) since September 2018 following a high number of below scoring outliers in the General Medical Council (GMC) National Training Survey (NTS), and with subsequent exploratory meetings that confirmed concerns for surgery residents, particularly for foundation residents. At the time of the 7 November 2024 meetings the QIR risk rating for foundation surgery at Ipswich Hospital was 12, Intensive Support Framework 2.

The purpose of this engagement meeting was to triangulate the experiences of surgery residents and to hear directly about their perceptions of progress and the support provided to them.

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 (2024) 2023 outcomes, and partial NETS 2024 outcomes (survey live at time of engagement)
• CQC Inspection Report 8 January 2020

Who we met with

Learners:

• 14 FY1&2, and Core residents
• 8 Higher (ST) residents across surgical specialties

Educators:

• 11 Trainers across surgical specialities and GOSW

Education team:

• Director of Medical Education
• Interim Chief Medical Officer
• Deputy CMO, Ipswich
• Head of Medical Education, ESNEFT
• Medical Education Manager Ipswich
• Clinical Lead, General Surgery & Consultant
• Consultant Colorectal Surgeon and Educational Supervisor
• ENT Clinical Lead and Educational Supervisor
• Clinical Lead, Breast Surgery
• Consultant Rheumatologist and Guardian of Safe Working
• Clinical Fellow, General Surgery and Rota master for OOH
• Rota Co-ordinator, General Surgery

Review panel

• Education Quality Review Lead, Marjorie Casey, Education Quality Manager.
• Patch Dean, Dr Francesca Crawley, Patch Dean for SNEE ICB and Deputy Foundation School Director
• Specialty Expert, Dr Helen Barker, Foundation School Director
• Specialty Expert, Miss Claire Edwards, Head of School of Surgery
• NHS England Education Quality Representative(s), Agnes Donoughue, Education Quality Coordinator. 

Review findings

Learning environment and culture

Both groups of residents praised the facilities and reported it was easy to arrange accommodation. All groups (residents and trainers) across surgery specialties reported there were good teaching opportunities, and consultants (and registrars) were helpful and wanted to provide teaching and training. When asked about the culture of the department, residents reported consultants were friendly and supportive, however both resident groups noted scope for cultural improvements and cited occasional belittling and incivility both within the department and from external colleagues. When asked if residents feel bullied, general surgery foundation residents reported they were supportive of each other, and that seniors may be supportive depending on who you are on shift with, but that within the department there were sometimes unhelpful comments, and some had been shouted at. T&O foundation residents felt they were generally better appreciated (than general surgery residents). Outside of the department, all groups of residents perceived interpersonal relationships with the ED were challenging, with rudeness reported to be common and ED colleagues felt to be unwilling to engage when referrals are questioned (RQ3). 

Multiple residents noted a lack of team cohesion and a competitive culture within the Ipswich Surgery Division, with higher residents perceiving consultants do not talk to each other, which can add to the workload as key information is not always reliably shared and there can be a lack of clarity regarding consultant responsibility for patients. There were comments about no cohesive strategy and many individual differences of opinion regarding the management of some conditions. T&O meetings were felt to be challenging with consultants questioning each other’s decisions. While there is a daily MDT trauma meeting, it may be the first time a consultant hears about each case, although the resident team may be very familiar with some of the patients being discussed on multiple previous days, but they may still be awaiting definitive treatment plans. There was also felt to be a lot of individualism in general surgery with no consultant led routine post-take ward round. It was reported there are times when a FY1 has been required to start the ward round, with registrar support coming in occasionally (between other tasks). Residents felt this necessitated speaking to multiple consultants, rather than one consultant lead, and can lead to delays in patient treatment. (RC1).

Educational Governance and Commitment to Quality

Trainers felt trust governance has improved since ESNEFT formed in 2019 and that significant work has gone into creating unified educational governance, with notable improvements over time.

Some residents described feeling discouraged from exception reporting and completing Datix, with some foundation residents seemingly unaware of the Guardian of Safe Working. Both groups of residents stated they do not submit exception reports, with foundation residents reporting processes take too much time and they lack belief that anything would change if they exception reported. Higher residents are also not exception reporting due to a perception that educational supervisors view exception reports as a negative reflection on themselves (RQ4).

Developing and Supporting Learners

Higher residents reported induction was insufficient, with limited formal induction and no contact numbers provided. Additionally, residents reported delays in receiving their rotas (rotas were not provided within the appropriate 6 weeks’ notice), and some residents experiencing long delays in access to IT systems and passwords, some of which were still unresolved weeks after starting (RQ5). Residents felt IT support was frustrating with long delays in responses and different details required for multiple systems. 

Both general surgery and T&O deliver regular weekly teaching programmes, with general surgery teaching noted to be more formal than T&O. In T&O teaching is led by registrars and then FYs and Core residents are given the opportunity to teach.  T&O foundation residents report good training opportunities, including clinics and procedures, and they are well supported by consultants who are available and accessible. One ortho-geriatrician (medicine) consultant was deemed to be especially supportive of foundation residents and praised for providing an excellent training experience through their efforts to ensure residents understand patient plans and discharge planning as well as providing cross ward support to residents in the event of trauma cases.

While T&O foundation residents felt they could always ask someone if they had a medical question, this was more difficult in general surgery where residents reported encountering difficulties finding someone to see patients if they required advice, particularly for patients who may also have medical issues. They reported the surgical registrar may not always review a patient under their care but will ask the foundation resident to contact the medical registrar, which can be uncomfortable (RC2).

Higher residents felt there was adequate coverage in the day, but that nights and weekends are more challenging, and foundation residents do not feel supported. At night there are 3 people covering the general surgical unit, generally a FY1, SHO and registrar. If the registrar is in theatre, they often require assistance from the FY or SHO, which may leave just one foundation doctor to cover inpatients and the acute take (RQ2). Patient care advice can be sought by going to theatre, but this is not ideal for the operating team or the resident who is already very busy. This is exacerbated by the requirement that residents escort patients to CT scans where contrast is to be administered, potentially taking one resident away from the ward for most of the shift (RQ2). Foundation residents reported night shifts are very stretched and that residents do not get breaks due to the busyness and pressures (RQ2, RC3). Residents commented that nurses would report them for not responding to a call straight away if they had taken a short break. Some residents had night shifts with no breaks at all, however this depended on the shift and seemed to be better in T&O compared to general surgery. It was felt that more foundation residents (expansion) would be helpful to alleviate pressure.

Foundation residents covering Urology report they may also be covering general surgery intakes on weekends and nights and that support may be very limited as Urology registrars tend to be offsite (split sites). Urology registrars were reported to be contactable and happy to be contacted in case of emergency, but the volume of work and high number of referrals overnight was perceived to place patients at risk and can be challenging. ENT overnight support for foundation residents was also reported to be challenging (RQ2).

In general surgery, residents commented that removing the twilight shift had a positive impact on the availability of annual leave but makes post-take days very difficult due to workload. Some residents wanted to bring back twilight shifts as they felt they had more time to handover tasks. General surgery residents feel the rota works well if everyone is in, but if there are absences the workload is overwhelming and there is a risk that patients can be missed during the hand-over to post-take. T&O trainers report that the department has tried to act on resident feedback and have reintroduced twilight shifts with 2 foundation doctors now scheduled on day shifts on weekends (instead of 1). General surgery trainers felt residents were less keen to reintroduce twilight shifts, though they noted staffing is better in the daytime, but felt the consensus was that the department did not want to reintroduce twilight shifts.

Higher residents felt that on-call support was good, but there is an issue with the ED making decisions regarding patient pathways, as per the ‘fit to proceed’ protocol that enables the ED to refer patients to the surgery division without appropriate investigations or notice, and once referred, require significant work to turn around to the appropriate division with time lags that were potentially dangerous (RQ1).  Further to this, residents sometimes felt unsupported by surgical consultants who have ‘told them off’ when an inappropriate referral has been accepted, but the ED do not provide an option of rejecting a referral (RQ3). Inappropriate referrals from ED were felt to add significantly to the workload, as the surgical team need to refer patients and seek tests to ‘prove’ the inappropriate referral (tests that are perceived would be easier and quicker for the ED to access) (RQ1).

Developing and Supporting Supervisors

Educators report they have time in their job plans and that funding is provided for training to both Locally Employed Doctors and Deanery residents. Trainers report they enjoy being educators but felt fuller rotas would enable better support to residents. They noted the longstanding lack of flexibility in the rota has a negative impact on training, making it difficult for residents to get to theatre. It is reportedly difficult to access locum cover if there are absences and recruitment often takes up to 3 months when there are vacancies which can mean the rota is regularly one down in staffing. It was felt the team are regularly working on the edge of capacity. 

When asked about surgical lists trainers noted there is a culture/perception in the division that patients ‘belong’ to individual surgeons (rather than everyone’s patients) and the surgeon is blamed when there are delays or surgery runs late (RC1). Some trainers felt theatre teams are good, but there can be issues with the lack of continuity (rotating residents) and some theatre team members are less supportive of the time required for residents to undertake procedures as they perceive they will take longer than their trainers. In the meetings the World Health Organisation (WHO) Surgical Education Checklist was referenced and suggested to educators as a useful tool to ensure training requirements are met and to clarify training expectations with the surgical team in theatre (RC4).

Delivering Curricula and Assessments

General Surgery trainers felt there is a good range of cases, and a mix from simple to very complex providing a good breadth of experiences but note operating time (theatre time) during the day can be lost for several reasons and it is difficult to enable residents to get to surgery for elective lists, with more staff required. Understaffing whilst maintaining safe working leads to a difficulty in balancing service delivery and training, with the latter suffering (RQ6).

Higher residents felt the case mix and surgery numbers are not sufficient to meet their curriculum requirements and expressed concerns about their ability to achieve their targets this year (RQ6). Residents reported long gaps between elective theatre opportunities and not enough specialty experiences. ENT trainers noted that for less senior Residents working in ENT, there is only one person the residents can swap with, which effects their access to educational opportunities. T&O higher residents reported insufficient access to elective theatre opportunities which inhibits their ability to reinforce learning and develop fluency (RQ6). Residents perceived there is a reduced number of cases compared with other placements over the same amount of time, and felt this was impacted by staffing issues and the way the theatre system is run, also not helped by the high number of elective cancellations. Adding to this, residents felt some anaesthetists within the surgical team are less welcoming and tolerant of the time required for training (RQ3).

Developing a Sustainable Workforce

Most foundation residents would recommend the placement for training but would not recommend the site for patient care (due to lack of overnight coverage) (RQ2). Though they felt the trust was good for some stages, most higher residents were reluctant to recommend Ipswich Hospital as a training site due to concerns they will not achieve their training requirements and felt it would be useful if extra lists were available to support getting through requirements. 

Areas that are working well

Good practice

Areas for improvement

Immediate mandatory requirements

Mandatory requirements

Recommendations

Good practice

Report approval

Report completed by: Marjorie Casey, Education Quality Manager
Review lead: Tracy Wray, Regional Lead for Education Quality
Date approved by review lead: 31 January 2025

NHS England authorised signature: Prof Bill Irish, Regional Postgraduate Dean/Regional Multiprofessional Dean
Date authorised: 3 February 2025

Final report submitted to organisation: 3 March 2025