Executive summary

This was a follow up review visit.  There was a previous visit to Paediatrics at Great Western Hospitals NHS Foundation Trust (GWH) in November 2024. The first visit was carried out in response to concerns identified from the GMC National Training Survey and the NHSE National Education and Training Survey, both 2024, and concerns identified through local quality processes in the South West. 

During the last visit, there were mandatory requirements for improvement and a follow up visit planned to review these at 6 months.  The mandatory requirements included;  

• Comprehensive IT and clinical induction for all new resident doctors
• Trust senior management to review staffing establishment with benchmarking to similar departments.
• Provide cover for compulsory teaching session attendance

At this visit, the Trust provided a positive and comprehensive presentation.  The resident doctors (RDs) were very positive about the department and could see the improvements that have been made since the last visit, particularly over the last few months. 

The panel were impressed with the Trust’s “You Said We Did” approach and there was a strong correlation between the feedback from Trust and the RDs, with all mandatory requirements addressed.  There is open dialogue between the leadership team, education team and RDs.

Progress has been made in consultant and tier 2 recruitment. The panel recognise the trust commitment to fund additional tier 2 night shifts until September. The plans to split the consultant rota in November should allow significant improvement to supervision provided. As will the additional twilight staffing based on trust analysis of workload data. The resolution of the longstanding issue with phlebotomy was also noted.

The panel are concerned that the number of advanced neonatal nurse practitioners (ANNP) currently being trained in the department is very high and the Paediatric School will liaise with the Trust to ensure that training opportunities for RDs are not affected. In the long term, having higher numbers of ANNPs will improve the skill mix and workforce, so some compromise is reasonable.

The panel would like to acknowledge the progress made and the work enabled to make it happen.  There are no mandatory requirements coming out of this report.  The panel would like to receive an update and review the September 2025 changeover in January 2026 with a School of Paediatrics led follow up, this could consider any unintended consequences related to the consultant split rota.

Review overview

Background to the review

This was a follow up review visit.  There was a previous visit to Paediatrics at Great Western Hospitals NHS Foundation Trust (GWH) in November 2024.  The first visit was carried out in response to concerns identified from the GMC National Training Survey and the NHSE National Education and Training Survey, both 2024, and concerns identified through local quality processes in the South West. 

Who we met with

Learners

• ST6 (represented all Paediatric Resident Doctors)

Educators

• College Tutor
• Clinical Lead
• Both represented all Paediatric Consultants

Education team

• Director of Medical Education
• Medical Education Manager
• Chief Medical Officer

Review Panel

• Associate Dean for Quality – Secondary Care  
• Associate Dean for Quality – Primary Care  
• Deputy Postgraduate Dean (Foundation)
• Head of School (Foundation)  
• Head of School (Paediatrics)
• Training Programme Director (ST 5-8 Paediatrics)
• Quality Fellow 
• Quality of Education and Training Officer  
• Patient and Public Representative   

Review findings

Domain1: Learning Environment and Culture 

The Trust induction to IT has been difficult in the past due to stretched IT teams and limited space. Previously, RDs received an initial talk followed by booking themselves into an IT systems induction session (except for Foundation Year 1, who receive this during their shadowing week pre-start).  From February 2025, a new system has been trialled: – the PGME team book RDs onto the training sessions, scheduling in collaboration with department rota leads.  This new approach has increased the percentage of learners receiving face-to-face IT training from 30% to 53%, with plans to review and improve further in August 2025. 

Concerns have been previously raised that the length of training time spent on Badgernet (the maternity IT system) was inadequate.  At the recent induction, the training time was doubled, logins were provided in advance, and there is a plan to make an easy-to-use guide for RDs.

The department collected feedback from RDs on previous department induction. Also, a QR code is displayed in the RDs forum room to provide anonymous feedback. Following this feedback, the less relevant sessions have been removed, allowing more time for useful sessions to be added. The panel commended this use of stakeholder feedback in improvement.

A department handbook has been updated and is emailed out to RDs 8 weeks in advance when they receive their rotas. A hard copy is available in the RDs forum room.  Within the handbook, a new induction sign-off sheet has been developed for RDs to discuss with their educational supervisor at their first meeting.

The RDs are positive about the changes that have been made to the department induction.  They now find it useful and structured better.

The RDs are encouraged to complete Datix and exception reports, particularly if teaching is cancelled or impossible to attend.

When RDs raised concerns around civility this was escalated by the RDs forum and was acted upon by the college tutor. The RDs have noticed a significant improvement in consultant behaviour and no new concerns have been raised in the last 3 months.

Domain 2: Educational Governance and Commitment to Quality  

A Paediatric RDs forum (RDF) has been set up jointly chaired with one of the RDs and the PGME pastoral lead since the last triggered visit to address the concerns. It is an open space for RDs and has improved communication between RDs and consultants.  RDs are encouraged to attend and can see concerns have been reviewed and followed up.  Consultants have actively engaged with the RDF, providing answers and suggesting how to escalate concerns.

Domain 3: Developing and Supporting Learners

The “blood list” (service phlebotomy) entailed large workload demands, causing a barrier to training and teaching.  Appointments were booked during Foundation teaching sessions.  The department and management have worked to improve this.  The phlebotomy team now support the department 4 mornings per week, focusing on the blood list rather than inpatients.  Appointments for the blood list no longer conflict with Foundation programme teaching.  These changes have reduced the workload for RDs and improved teaching opportunities.  Further work will be done to try and extend the phlebotomist support to cover the afternoon slots, but the Trust are focusing on ensuring the morning sessions are running efficiently before increasing the service into the afternoon.

Concerns were noted in the last visit on the fragile staffing at all levels, resulting in inadequate educational and clinical supervision and a high workload causing burnout for RDs.

Foundation RDs were being placed solo on the postnatal ward, making them feel unsafe with limited learning opportunities and no teaching. We were told that changes have been made to the rota ensuring that pre-registration Foundation year doctors will no longer be without direct supervision. They will be with a post-registration doctor and a “transitional” nurse.

Foundation Year Ones are no longer carrying the referral phone, as identified in the last visit.

The consultant led board rounds are now done at a new time after the safety huddle to ensure more reliable availability of the consultant.  The emphasis is on teaching as part of the round.  The RDs confirmed better supervision is now provided and learning opportunities have improved.

The RDs reported seeing substantial improvement to the rota over the last couple of months.  A weekly rota circulation is now in place allowing to easily identify where shifts have not been filled by locums.  Self-rostering is now used for tier 2, with positive feedback and is being considered for tier 1.

Supervision and staffing at night have been a concern for tier 1 and 2 doctors.  With only one tier 2 doctor at night, the tier 1 doctors felt there was insufficient supervision and the tier 2 doctors struggled with the workload.  The Trust have been working to improve this and did a trial with two tier 2 doctors at night.  Feedback via the RD Forum has been positive, the tier 1 doctors feel supported, and the workload is manageable, but this trial is not sustainable with the current numbers of tier 2 doctors in the department.  If the shifts cannot be filled, they go out to locum but they are not always filled.  When this occurs, consultants need to act down and this has a wider impact on the department.

The Trust have a long-term plan to have an additional registrar “tier 2” doctor on a twilight shift from 4pm until midnight, in addition to the tier 2 doctor on the night shift. In September, the Trust will move from a 1:7 registrar rota to a 1:10 registrar rota.  This will allow study days, teaching days, clinics and admin time as well as the addition of the twilight shift registrar from 4pm until midnight to reduce the workload on the night registrar.

Six-month blocks in Neonates and General Paediatrics are currently under consideration for ST1s to help improve continuity. This may also be helpful to ensure fair access to neonatal and paediatric procedures across trainees.

Domain 4: Developing and Supporting Supervisors 

The PGME department distributes the NHSE tariff to the paediatric department for job planned educational supervision; In GWH this is paid at 0.25 PA for the first trainee, 0.125 PA for 2nd trainee and 3rd trainee, to a maximum of 0.5 PA.  The rationale for this policy with no job planning renumeration for a 4th or further supervisees is inconsistent with the NHSE Education Funding Agreement 2024-27: Schedule 1 : 12.37.2

“the Placement Provider’s Director of Medical Education (or nominated equivalent) will make formal recommendations on the numbers of programmed Services and/or sessions to be addressed in consultants’ …job plans as a minimum of 0.25 PA per Learner supervised”.

Domain 5: Delivering Curricula and Assessments

A new teaching timetable has been created, with separate days for tier 1 and tier 2 RDs. This change enables teaching more relevant to their educational needs and all teaching is bleep free.  There is a well-established neonatal simulation training programme occurring monthly and a new monthly general paediatric simulation training programme has started.

The tier 1 rota has specific departmental study days; in total 7 of these days in a 14-week cycle. These specific days allow self-directed learning and are separate to their GP and Paediatric training and study days.

New evidence-based educational resources for tiers 1 and 2 have been developed and are hosted within the departmental section on the Trust network. These resources include teaching sessions, appropriate calls and external resources for e-learning.

ST1s have raised concerns with the Trust over competition for neonatal procedures with trainee ANNPs and being pulled to the postnatal ward more frequently resulting in their experience being limited in other areas of the department.  A new process for distributing learning opportunities in neonatal procedures is being implemented; the DME has been liaising with the Head of School, along with the department team and rota coordinators. Changes have been implemented to ensure fair distribution, but RDs feel further discussions are required to define clearer roles and improve the experience for everyone.

The RDs confirmed a consultant has started teaching clinics to improve outpatient clinic experience.  The RDs can book their own slots.

Domain 6: Developing a Sustainable Workforce  

There is a PGME tier 1 clinical education fellow in the department (50:50 clinical).  They have been able to help facilitate teaching programmes, assist with support of Foundation years and perform work-based assessments. PGME have secured a 2^nd clinical education fellow (tier 2, 50:50 clinical) hoping to start September 2026, (timed to coincide with paediatric speciality training rotation). This will ensure there is always an educational presence in the department, and they can support with the simulation programme.

Feedback from RDs indicated that the dedicated transitional care nurse is supportive and helpful. There is a long-term plan to have a transitional care-based consultant when consultant expansion occurs.

Two neonatal consultant posts have been recruited , and will be starting in September/October 2025.  Once these posts have been filled and inducted, the consultant rota will be split in November 2025.

The Trust are currently training a cohort of ANNP. They hope to implement a full 24/7 staffed ANNP rota by 2026/27; they will be an additional member of the team to help support the workload of RDs.

Previously, the College Tutor was also the Clinical Lead, which could represent a conflict of interest in Educational Governance. These roles are now undertaken by two individuals.

Areas that are working well

Good practice

Areas for improvement

Recommendations

Report approval

Report completed by: Ilana Langdon, Associate Dean for Quality, Will Wallage, Associate Dean for Quality (Primary Care)
Review leads: Ilana Langdon, Associate Dean for Quality, Will Wallage, Associate Dean for Quality (Primary Care)
Date approved by review lead: 3 July 2025

NHS England authorised signature: Geoff Smith, Regional Postgraduate Dean
Date authorised: 5 August 2025

Final report submitted to organisation: 26 September 2025