Executive summary

The results for the 2024 General Medical Council (GMC) National Training Survey (NTS) showed multiple categories where responses were below the national average at KGH in surgery. To better understand their experience of the clinical learning environment, a learner educator meeting was arranged for March 2025. We spoke to foundation, core and higher resident doctors in urology, general surgery and trauma & orthopaedics (T&O).

Foundation, core and higher resident doctors were highly complimentary about the surgical departments with regards to team ethos and exposure to training opportunities. They did however highlight some areas that were negatively impacting their education and training experience.

There was a clear consensus amongst the foundation doctors that starting their first post in surgery can be a daunting experience because they reported being ‘thrown in at the deep end’ but acknowledged that this experience is also a good learning opportunity.

Induction feedback was variable as not all foundation resident doctors managed to attend, and concerns were highlighted regarding the general surgical on call inductions. They did however report that the handbook is a useful tool.

Senior support was reported as a concern for foundation resident doctors across several areas. Foundation year one resident doctors in the T&O department raised concerns regarding managing ward rounds and T&O referrals from the emergency department on their own.

Foundation resident doctors in general surgery advised that they felt the weekend shift (8am – 5pm) is unsafe due to the lack of senior resident cover.

The A&E online referral system was also reported as a concern due to receiving a high volume of inappropriate referrals resulting in delays to patient care.

In summary, the areas highlighted that need addressing are:

• Foundation year one resident doctors managing ward rounds on their own in T&O.
• Foundation year 2 resident doctors reported feeling out of their ‘depth and working outside their competence’ during on calls in T&O.
• It was reported that the weekend shift in general surgery (8am – 5pm) for foundation resident doctors is unsafe due to the lack of senior resident cover.
• The A&E online referral system was reported as delaying patient care in T&O due to receiving a high volume of inappropriate referrals.
• Not all foundation resident doctors were able to attend induction due to being on-call.

As a result of the required improvements identified, we will be recommending that an Intensive Support Framework (ISF) category 2 is applied. A trust improvement plan will be required against the immediate and mandatory requirements outlined in this report.

Review overview

Who we met with

Learners

Foundation, core and higher resident doctors in surgery specialities – urology, T&O and general surgery

Educators

Clinical and Educational Supervisors
Service Lead
College Tutor

Education team

Director of Medical Education
Deputy Director of Medical Education

Review panel

Rachel Parry, Foundation Head of School, LNR
Gillian Tierney, Surgery Head of School
Kerry Olley, Quality Deputy Manager

Review findings

Support, supervision and workload

T&O

Foundation resident doctors reported the support from core and higher resident doctors as good. They added that they are approachable, always willing to help, and often go above and beyond working past their shifts to provide support to foundation resident doctors. KGH in general was described as a good place to learn, however, concerns were reported around the availability of consultant support for foundation resident doctors in T&O and general surgery.

Foundation year one resident doctors in the T&O department reported managing ward rounds on their own during the day. They reported that in some cases they are left on their own to see day one post operative patients without a further senior review. It was reported that there are no scheduled consultant ward rounds in place. During the educator session it was acknowledged that foundation year one resident doctors should not be on their own but due to sickness this inevitably happens.

Foundation resident doctors reported that although they feel supported by colleagues in T&O they are left to deal with medical issues on their own and must contact the medical higher resident doctors for support. Foundation resident doctors reported that they have concerns with the lack of leadership in terms of making end-of-life decisions for patients. Core and higher resident doctors also reported that support for end-of-life care decisions would be made easier for foundation resident doctors if they had dedicated medical support.

Foundation year 2 resident doctors reported feeling ‘out of their depth and working outside their competence’ during on calls. They reported managing T&O A&E referrals whilst also managing the inpatients without previous trauma experience. It was reported that they have a trauma nurse practitioner (TNP) with them until 4am and then they are the only clinician on site until 8am. They reported that there is a higher resident doctor on the rota who is non-resident, however, that doctor is predominantly covering theatre so is often unavailable. The department however confirmed that the on-call registrar is not allocated to theatres and is freed from other activities to be available to support the acute on call team. Out of hours (such as weekend daytime) they also reported that they have arrangements so that they are not allocated in trauma theatres. It was reported that the higher resident doctors are extremely supportive and will stay several hours after their shift has ended to support the foundation resident doctors. Some foundation resident doctors reported that sometimes they are ‘lucky’ if their higher resident doctor is not in theatre and available to support them, however, this is rare.

It was reported that the trauma meeting that takes place every morning works well, and the night doctor goes through all the patients that have been admitted during on call, and all x-rays are reviewed. Foundation resident doctors advised they were well supported in this meeting.

Workload is being reported as high in T&O by all levels of resident doctors which the educators also acknowledged and confirmed this has been flagged in their trust governance meetings.

General surgery

In general surgery it was reported by foundation resident doctors that the weekend shift (8am – 5pm) is unsafe due to the lack of senior resident cover. It was reported that there is a high amount of patient reviews, and they reported that they are largely unsupported because the higher resident doctor, who is also on the ward, is allocated to emergency theatre. They reported being left to make discharge decisions without senior support. They added that they often work additional hours to get all the jobs done and give a sufficient handover. They did advise that this has already been reported to the guardian of safe working, however, as no patient safety incident occurred, they were advised that this was not a reportable incident.

It was reported during the educator session that this feedback was also raised within the department and as a result they created another shift 8 – 2 on the weekends so that there was extra support, but due to funding cuts this has now ceased. It was reported that previous colleagues who worked in the department when this change was implemented had been very complimentary about this change and without this extra member of staff it is having a detrimental impact on education and training.

Induction

It was reported that the urology department had a structured induction on the first day, and foundation resident doctors felt well-supported. There was also a specialist urology practitioner whose extensive knowledge of both clinical and logistical aspects was incredibly helpful. Additionally, a handbook was provided, which was reported as being a useful resource. Overall, the urology induction was reported to be well-organised and beneficial.

In general surgery some of the foundation resident doctors were unable to attend the induction due to being on-call. No replacement session was offered, meaning some foundation resident doctors did not receive a formal induction.

Foundation resident doctors advised that the general surgical handbook was helpful, and some foundation resident doctors were fortunate enough to have an F1 shadowing week in general surgery, which provided some useful insights.

Colleagues who were at the induction in person, reported that even those scheduled to attend were often unable to because the wards were too busy. Senior resident doctors attended the induction, whilst junior resident doctors were left to manage the wards. As a result, most of the junior resident doctors in the first rotation did not receive a formal induction.

Regarding on call inductions in general surgery, resident doctors in urology advised that they did not receive a specific induction for the on-call shifts and are expected to learn on the job, relying on colleagues in the department for guidance. While the induction handbook was valuable, they reported that without it, they would have been lost on the first day and added that expectations of foundation resident doctors became clear only as they progressed through the different shifts.

Accident and emergency referrals – T&O

Foundation, core and higher resident doctors reported that the A&E online referral system (e flow) is causing issues. It was reported that the system operates as a one-way process, lacking a function to decline inappropriate referrals. As a result, there are delays in directing patients to the appropriate department which is having an impact on patient care. Additionally, it was reported that the quality of referrals has been suboptimal, further complicating the process.

It was acknowledged that A&E are also under significant pressures with patient flow. It was suggested that if there was a mechanism in place on the system where referrals can be reviewed with an option of being rejected if it is inappropriate for the patient to be sent to T&O, this would speed up the process for patients.

Immediate mandatory requirements

Mandatory requirements

Report approval

Report completed by: Kerry Olley, Quality Deputy Manager
Review lead: Rachel Parry, Head of school for Foundation
Date approved by review lead: 26 March 2025

NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean
Date authorised: 8 April 2025

Final report submitted to organisation: 9 May 2025