Executive summary

This learner and educator review of Neurology training at Imperial College Healthcare NHS Trust (Charing Cross Hospital) sought to understand in greater detail some of the issues within the department for resident doctors, as well as gaining a holistic understanding of the department from the managerial and educational team, and the clinical and educational supervisors.

The NHS England – London review panel were pleased to hear that resident doctors spoke highly of the Neurology consultants, nursing team and the Neurology Ophthalmology multidisciplinary team (MDT), and that the Trust had clinical cases and specialist clinics which would be of great benefit to resident doctors training in Neurology.

However, the panel identified the following areas for improvement:

• Staffing numbers and the rota arrangements meant that resident doctors were too busy prioritising other areas of work and were unable to attend the majority of clinics available to them.
• The new curriculum requiring Neurology resident doctors to undertake work in General Internal Medicine as well as Stroke Medicine which meant that there was a loss of colleagues working within Neurology when rotating to Medicine, and these posts were not backfilled, which had an impact on training for Neurology resident doctors remaining on the Neurology rota.
• There was a lack of a local teaching programme for resident doctors, with a single consultant responsible for devising this.
• Induction was limited or non-existent for some resident doctors in Neurology.

The panel assigned provisional Intensive Support Framework (ISF) ratings for the following programmes:

• Neurology: ISF 2
• Internal Medicine Training (IMT): ISF 0

NHS England’s Education Quality Team will monitor the responses to the mandatory requirements detailed in this report during the quarterly Quality Management Portal (QMP) action cycle.

Review overview

Background to the review

NHS England – London scheduled this Education Quality Intervention due to concerning feedback in the General Medical Council’s National Training Survey (GMC NTS) 2024 and information received in the self-report submitted by Imperial College Healthcare NHS Trust.  

The GMC NTS 2024 results under programme group by site for Neurology at Charing Cross Hospital flagged eight red outliers and five pink outliers as per the following: 

Red outliers: overall satisfaction, workload, adequate experience, educational governance, feedback, local teaching, study leave, rota design.  

Pink outliers: reporting systems, induction, educational supervision, regional teaching, facilities. 

NHS England felt that a quality intervention would be the most appropriate course of action to understand the issues in more detail and formulate a shared action plan between the Trust and NHS England.   

Who we met with

Learners

• 11 Resident Doctors training in Neurology and Internal Medicine Training (IMT) at Imperial College Healthcare NHS Trust.

Educators

• 8 Clinical and Educational Supervisors for the Neurology training programme.

Education team

• Clinical Director
• Medical Director
• Associate Medical Director – Education
• Divisional Director for Medicine
• Unit Training Lead (UTL) for Neurology
• General Manager for Stroke and Neurology
• Training Programme Director for North West London
• General Manager – Medical Directors Office
• Medical Education Manager
• Postgraduate Education Manager
• Education Service Manager

Review panel

• Education Quality Review Lead, Dr Richard Bogle, System Dean – North West London, NHS England
• London Specialty School of Medicine Representative, Dr Clifford Lisk, Deputy Head of the School of Medicine, NHS England
• Specialty Expert, Dr Paul Jarman, Training Programme Director – Neurology
• Lay Representative, Kate Brian, NHS England
• London Education Quality Representative, Nicole Lallaway, Education Quality Coordinator, NHS England

Review findings

Staffing levels and rota arrangements

The panel heard that Neurology training in North West London was five years long, with training across five different hospital sites, typically lasting one year for each site: Charing Cross Hospital, St Mary’s Hospital, London North West University Healthcare NHS Trust, Chelsea and Westminster Hospital and National Hospital for Neurology and Neurosurgery. The panel heard that the rota was complex, with Resident Doctors (RD) working across multiple hospital sites and covering different rotas.

The review panel found that the staffing level within the Neurology department had a major impact on training for RDs, which was further compounded by recent changes in the curriculum and the way the service was delivered. The panel heard that under the new Neurology curriculum, RDs were required to gain additional experience within General Internal Medicine (GIM) and Stroke Medicine over the course of a year, and this meant a loss of time learning about Neurology during their five-year programme. In addition, the panel heard that when RDs rotated into GIM, the Neurology posts were not backfilled, which increased the workload for the RDs remaining in the department.

The Trust informed that there was ongoing work to make changes in these areas with the goal to improve the RDs experience. These included all vacant posts now being filled, proposed plans to increase the number of Clinical Fellows within Neurology from 3 to 6, and the transition to 1 rather than 2 out of hours and weekend rotas from August 2025. In addition, the panel heard that the rota at present accounted for 1 in 16 members of staff, and that it planned to increase this to 1 in 24, with the aim to have extra colleagues working to account for any sickness absence of zero days. The Trust also reported that there were ongoing discussions around the identification of medical posts and backfill options for Neurology RDs working in GIM. NHS England’s panel felt the Trust’s plans to increase numbers of staff working in Neurology was appropriate and was supportive of the Trust’s plans to transition to 1 rota, however the panel has reservations about the potential increase in workload that could ensue for the RD rostered. The panel felt that the Trust should work closely with RDs on this rota design to ensure its sustainability, as well as monitor how the rota was working for RDs in Neurology.

The Trust reported that St Mary’s Hospital had a busy Emergency Department (ED) and Major Trauma Centre, and that there was a 32-bed Intensive Care Unit (ICU) which had a high volume of patients with neurological problems and trauma who required a specialist neurology opinion. The panel also heard there was a Same Day Emergency Care (SDEC) or ‘Hot Clinic’ at St Mary’s Hospital which Neurology RDs worked in as well. However, it was noted there was no neurology SDEC at Charing Cross Hospital to enable urgent review of patients who had been seen in the Charing Cross Hospital Emergency department. The Neurology department at St Mary’s Hospital initially had 3 RDs, but with the new curriculum requirement to undertake GIM, the rota often had 2 RDs working due to no backfill to Neurology. It was reported that these RDs often had a large workload due to this, and if there was any sickness absence or zero days, this left 1 RD working within the department. When this was the case, the Trust would try to recruit locum doctors to fill the gap, as managing the hot clinic, SDEC, referrals and administrative tasks would be too onerous for RDs. However, RDs reported that often the locums recruited would be new to the hospital and did not have badges, access to the electronic systems and did not know how the department worked. This created additional workload for RDs who had to train the locum doctors each time they were new to the hospital. It was reported that there was a consultant working 9am – 5pm if RDs needed support, however the busyness meant that RDs could rarely attend non-emergency general neurology and specialist neurology clinics and lost valuable training opportunities.

Neurology RDs also reported that the volume of work from Western Eye Hospital into St Mary’s Hospital was considerable, and that this volume of work was felt to be unmanageable. Educational Supervisors (ES) reported that the plan for Neurology referrals from the Western Eye Hospital would be limited to specific postcodes, and that generally patients referred outside of these postcodes would not be accepted. However, it was noted that if there were urgent concerns about the patient’s condition, the hospital would take responsibility for these patients regardless.

The review panel were pleased to hear that RDs would be happy for their friends and family to be treated within the Neurology department once they were admitted to the 10 North ward at Charing Cross Hospital, but it was noted that getting to the stage of admission to the hospital from the St Mary’s Hospital ED was difficult. However, there was some hesitation from RDs when asked if they would recommend their placement to other Neurology RDs.

Access to learning opportunities

RDs training in Neurology and Internal Medicine Training (IMT) reported that although clinics were on the timetable, they were frequently unable to attend these due to their workload in other areas and staffing levels. The loss of Neurology RDs to GIM and Stroke Medicine meant that there were fewer members of staff working on the Neurology rota, and that colleagues taking study leave, annual leave, sick days and zero days further impacted RDs ability to attend clinics. The panel heard that the clinics RDs did attend were excellent and that they were well clinically supervised by consultants. However, most of the Neurology RDs were concerned about meeting their competencies, and it was felt that this had a major impact on their development as consultants who would eventually be required to run clinics once they completed their training. Whilst RDs were able to spend time in the Hot Clinic / Same Day Emergency Care (SDEC) at St Mary’s Hospital, this was not the same as getting exposure to a general neurology or specialist Neurology clinic and did not appropriately cover aspects of the Neurology curriculum for RDs.

The panel found that there was not a clearly defined local teaching programme for Neurology training and where teaching sessions did occur, work pressures meant that most RDs could not attend these sessions. RDs felt that teaching was largely provided on an ad-hoc basis, and that teaching from consultants was good during referrals and clinics when RDs were able to attend. The panel heard that there was a weekly academic meeting on Fridays where a RD would be asked to present a case/patient that was currently admitted to the ward, however RDs felt this did not have much value as a teaching method with limited preparation and support for the presentation of the case. The panel felt that the department would benefit from having a dedicated consultant with oversight of the full teaching programme within Neurology.

The panel heard that Stroke Medicine at Charing Cross Hospital was felt to be overwhelming for some RDs, who reported that they were responsible for the bleep which received numerous calls, whilst also being responsible for administrative tasks. RDs felt that this workload meant a loss of learning time within their stroke placement.

RDs highlighted that they were responsible for prescribing medication for patients attending the Neurology Day Unit for infusions and treatments. This entailed prescribing for approximately 50 complex patients and for patients on the wards that they had not met or dealt with medically. It was felt that this piece of work could be undertaken by another appropriately qualified healthcare professional (e.g. prescribing pharmacist or clinical nurse specialist) to enable more time for RDs to focus on education and training.

RDs reported that whilst they sometimes had to chase some consultants to get their workplace-based assessments signed off, the quality of feedback and commentary when received was excellent.

RDs had positive working relationships with their nursing colleagues on the wards and felt that working with the Neurology Ophthalmology multidisciplinary team (MDT) was a good learning opportunity which gave them confidence working on complex Neurology cases.

Induction

RDs reported that their induction into Stroke Medicine was excellent with shadowing on the ward and a large focus on safety protocols, however the quality of the induction for Neurology was variable. The panel heard from some RDs that they had a good induction when they began their placement with other RDs, however some RDs reported that if they were part of a smaller cohort when they began their Neurology placement, there was no induction. Experiences reported included not being introduced to colleagues working on the ward and having to undertake a ward round for approximately 20 complex neurological placements without a prior induction. Some RDs reported that there was a Neurology handbook available if RDs were unsure of processes. In addition, the panel heard that there was no induction for RDs when they began the GIM aspect of their placement.

Raising concerns

While Local Faculty Group (LFG) meetings took place and RDs were able to attend this, the panel heard that often the same issues would be raised any no changes would be made within the department. The panel felt that the inclusion of management representation at LFGs would have a positive impact on making positive changes for RDs Neurology training. 

The panel heard that some RDs were discouraged from exception reporting by some consultants, and RDs had a reluctance to complete these when they worked late. It was reported by RDs that working late was not felt to be an ‘exception’ which also contributed to some RDs not submitting exception reports. The department should work to ensure that exception reporting becomes part of normal business and use the information gained to further refine rotas and work plans.

Clinical supervisors

The review panel were pleased to hear that all RDs in Neurology and IMT had an ES allocated, and they spoke highly of their Neurology consultants. RDs felt consultants were supportive and provided good clinical supervision in and out of hours and were keen to teach. RDs also reported that they did not have any issues with contacting Neurology consultants if they required support with a particular patient.

The panel heard that there were no Neurology beds at Hammersmith Hospital. It was noted, however, that the specialist clinics at Hammersmith Hospital were good for seeing Neurology patients in the context of other illnesses, and that this role was more specifically weighted towards the more senior RDs in Neurology. RDs reported that the consultants at Hammersmith Hospital were excellent, however it was reported that consultants were not necessarily based on-site, which meant that sometimes patients would not be seen by a Neurology consultant for up to 3 days.

The panel were pleased to hear that all clinical and educational supervisors had undertaken the required training to prepare them for their role as educators. This included their initial ES training, and training sessions every 3 years facilitated by the postgraduate medical centre. It was also reported by ES’ that they found the Royal College of Physicians (RCP) training beneficial to learn how to approach RDs requiring additional support. ES’ also reported that they had their educational appraisals included in the Trust’s annual appraisal process.

The panel heard that the GIM component of Neurology RDs training was supervised by a different group of consultants working in Medicine.

Some ES’ reported that they were not fully clear on how to support IMT RDs if they were allocated as their ES, but that they could get some advice from the TPD if required.

Some ES’ felt that they could be better foretold of any RDs requiring additional support to better prepare them when RDs rotate into the Neurology department. For example, by their previous Trust or the TPD. It was felt that handovers when RDs rotate into the department should be more thorough where required.

ES’ expressed concerns about Neurology RDs limited exposure to specialist clinics due to their workload, and noted that when RDs are rarely able to join, sometimes this is just to see between 1 to 4 patients as opposed to a whole clinic.

General internal medicine and stroke medicine

RDs reported that the Training Programme Director (TPD) organised the GIM component of Neurology RDs training, which took place at either Charing Cross Hospital, St Mary’s Hospital or Ealing Hospital. RDs reported that it was unclear whether their placement in Stroke Medicine contributed to their GIM training year, and that with the objective of seeing 750 patients in GIM, RDs felt that they may not reach that by the end of the 5-year programme. NHS England noted that placements in Stroke Medicine should count towards RDs GIM year and that this will be picked up by the TPD.

The Trust reported that when RDs rotated into GIM, they were fully emersed with the medical team, working on the medical take and medical clinics, whilst also undertaking some Neurology clinics and attending x-ray meetings to keep in touch with their base specialty.

Internal medicine training

The panel heard that there were 3 IMT RDs, with 3 IMT RDs working on the Neurology rota on the 10 North ward, one Specialty Training Year 1 (ST1) working in Neurosurgery and one Foundation Year 3 (F3) post that was recently filled.

The panel heard that IMT RDs were expected to be responsible for medical outlier patients who were admitted to the 10 North ward. RDs reported that this was an expectation placed upon IMT RDs by the medical team without initial input from the Neurology department, and that when this was raised, IMT RDs were no longer asked to be responsible for these patients. However, the panel felt there would be benefit in having explicit communications from the Neurology department to the IMT RDs, detailing that they were not expected to cover the medical outliers on the 10 North ward.

Areas that are working well

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Nicole Lallaway, Education Quality Coordinator
Review lead: Dr Richard Bogle, System Dean – North West London
Date approved by review lead: 9 January 2025

NHS England authorised signature: Dr Elizabeth Carty, Interim Local Postgraduate Dean
Date authorised: 9 January 2025

Final report submitted to organisation: 14 January 2025