Executive summary

NHS England Workforce Training and Education South West carried out a triggered quality review in response to concerns identified from the GMC National Training and NHSE’s National Education and Training Surveys 2024 as well as concerns identified through local quality processes.

Overall, the review found a number of areas where the quality of the learning environment should be improved.  These principally relate to fragile staffing at all levels, resulting in often inadequate educational and clinical supervision and high workload to the point of burnout for resident doctors. Induction is variable in quality and should be improved to a consistent acceptable standard. 

It was noted that the educators are committed and approachable and provide high quality assessments and teaching when workload permits. Teamwork and respect for all in the team is very good.

Staffing is a major theme of concern across all grades.  Resident doctors believe that this has a potential impact on patient safety although no instances of harm were described to the panel.  Registrar level doctors are unable to adequately support foundation or GP speciality training doctors in clinical work, and similarly consultants are too stretched across the various parts of the department to support either level of resident doctor.  The Tier 2 (middle grade/registrar) rota is only 5/8 WTE staffed from December 2024.

The findings were communicated to the Chief Medical Officer on the day of the visit, who confirmed that staffing in paediatrics is a focus for the trust, with a business case for consultant posts in process.

The visiting team and panel lead in discussion with the Regional Postgraduate Dean agreed to communicate the findings to the Regional Clinical Quality Director and his team where these were described to present a potential threat to patient safety and regarding safe staffing levels.

Review overview

Background to the review

Multiple data sources (General Medical Council National Training Survey, National Education Training Survey and Regional Quality Panels) indicated that Great Western Hospital NHS Foundation Trust was not providing adequate quality of education and training across a number of programme groups/specialties in paediatrics, despite early intervention by the relevant Schools and SW Regional quality team input. After discussion at the Quality Scrutiny Oversight Group this visit was arranged to target areas of concern.

Who we met with

Resident doctors from the following programmes:

• F1 (Foundation 1)
• F2 (Foundation 2)
• GPST (General Practice Speciality Training)
• Paediatric Speciality Training

Educators

• Consultants, College Tutor.

Education team

• Director of Medical Education, Associate Medical Director/Academy Dean.

Review panel

• Associate Deans for Quality – Secondary Care and Primary Care
• Head of School and Training Programme Directors for Paediatrics
• Foundation School Director
• Patch Associate Dean for GP training
• Lay representative
• Quality of Education and Training Officer

Review findings

Learning environment and culture

The panel heard that the most recent departmental paediatric induction in September 2024 was poor as resident doctors did not have tours of the department from senior colleagues and did not receive timely IT access. This was in contrast to the previous induction in March 2024, where there were no significant issues. Resident doctors were made aware of their supervisors during each induction.

Educational governance and commitment to quality

The trust is aware of paediatric rota gaps but the resident doctors told the panel that there is pressure to accept gaps rather than pay higher agency rates in the currently financially restricted environment if cheaper bank locums cannot be found.

The panel heard that due to the Tier 2 (middle grade or registrar level) paediatric doctors covering multiple different clinical areas they are often not able to offer direct supervision to Foundation doctors, Tier 1 Paediatric (in the first 3 years of training) and GPST resident doctors.

The panel heard that the paediatric referral phone is held by whoever is on the Tier 1 shift and this can mean that foundation doctors are accepting referrals without the experience to properly triage on the phone. This results in more patients coming to the department which exacerbates workload pressure.

At weekends, whilst covering multiple areas of paediatrics including Neonatal Intensive Care Unit, the paediatric ward and the Children’s Emergency Department, the lack of supervision across each area can make more junior Tier 1 paediatric resident doctors worry that some areas are unsafe as they do not have the necessary level of clinical competence to provide safe care NICU without more senior supervision being available.

Developing and supporting learners

The panel heard from GP resident doctors that whilst not official policy, there is an apparent acceptance from the GP education faculty that they are unable to attend allocated GP teaching sessions whilst on the paediatric rotation.

Resident doctors in paediatrics said that the registrars and consultants were happy to sign off work-based assessments (WBA) or supervised learning events (SLE) and were very approachable, but that there was sometimes a delay or even a failure to completing the assessment because of workload pressures for the senior colleagues.  Whilst educational supervision is job planned; it is often physically undeliverable.

Developing and supporting supervisors

Paediatric supervisors said that they struggle to capitalise on the many available educational opportunities as the Paediatric Assessment Unit (PAU) is too busy. The department have recruited two new consultants but one will not be in post until February 2025. They are advised that tight financial constraints will prevent any further investment in staffing.

In paediatrics, the number of supervisees is generally 3-4 per consultant, and job planned, but clinical and educational supervision can be challenging to deliver due to high clinical workload encroaching into SPA (Supporting Professional Activity) time. 

Delivering curricula and assessments 

In paediatrics, the workload is preventing resident doctors from utilising available learning opportunities. Work-based assessments (WBAs) are hard to complete as resident doctors are rarely observed in clinics. The panel heard that registrars have offered to have more frequent case-based discussions with more junior (Tier 1) resident doctors and were described as ‘excellent’ by those present. Some consultants are good at signing off WBAs quickly and others are not, but generally this was felt to be due to workload pressure.

Developing a sustainable workforce 

The panel heard from the resident doctors that the paediatric registrar (Tier 2) rota is designed for ten whole-time-equivalent (WTE) posts (later trust response was that this is for either eight or nine WTE, depending on staffing levels), whereas from next month there will only be five WTE in post. Locums are therefore required to fill gaps in the rota. Locums are not always familiar with the trust, and of variable quality.  This has the resultant effect that locums often leave resident doctors on night shifts additional work that should have been completed within the day. This is contributing to burnout from high workload pressure. Some resident doctors said that out-of-hours care was unsafe because there is only one “senior decision maker” – i.e. Tier 2 doctor out of hours, whereas most paediatrics departments of a similar size would have two.  One of the Royal College of Paediatrics and Child Health (RCPCH) “Facing the Future” standards for quality of care is that every child with an acute presentation should be seen by a Tier 2 doctor within 4 hours, which is very difficult with only one senior decision maker present out of hours. The trust could consider an audit against this standard to inform adequate rota planning.

Paediatric Resident doctors said they rarely if ever exception report as it is seen as another demand on their time and the exception reports are rarely addressed in a timely manner or have any impact. 

Development of wider workforce transformation roles to support the workload were not described to the visiting panel. Options for workforce transformation should be considered by the department and trust leadership. Examples of good practice should be sought from similar departments across the region. The panel subject matter experts offered to assist with this.

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Ilana Langdon, Associate Dean for Quality
Review lead: Ilana Langdon, Associate Dean for Quality
Date approved by review lead: 15 January 2025

NHS England authorised signature: Prof. Geoff Smith, Regional Postgraduate Dean

Date authorised: 17 January 2025