Executive summary

Due to ongoing concerns within acute internal medicine (AIM) and from a Lancashire Teaching Hospitals NHS Foundation Trust (LTHTr) internal report a learner/educator review was arranged to see AIM and general surgery resident doctors.

Verbal feedback was provided to the Director of Postgraduate Medical Education (DME) on the day of the visit.

There were 2 immediate mandatory requirements identified which were

• Some wards do not have advanced life support defibrillators, i.e. those with added functions such as cardioversion and pacing.
• Foundation doctors in general surgery, are not receiving direct supervision as required by the GMC, local induction or support with QI projects.

Positive findings from the review include:

• Good experience in geriatric medicine, diabetes and endocrinology and respiratory medicine. The specific wards were not mentioned in geriatric medicine or diabetes and endocrinology.
• Good handover in gastroenterology.

There are 3 mandatory requirements identified

• Resident doctors not to make decisions outside of their competencies.
• Planned rota gaps to be covered.
• Welfare and support information to be provided for doctors returning from maternity leave.

There was one recommendation asking the trust to consider the use of handover lists at Chorley.

An action plan for the immediate safety requirements was submitted by the trust on 25 November 2024. A senior leadership meeting to discuss the report will take place with the trust on 16 December 2024.

Review overview

Background to the review

The deanery last met with resident doctors and their supervisors in Acute Internal Medicine (AIM) at Chorley on 5 July 2023. This was triggered by the 2022 GMC National Training Survey (NTS) results. A Senior Leadership Meeting to discuss the findings with the trust took place on 3 October 2023.

The visit was positive with 2 recommendations which the trust chose to take forward. These were 

• frequent clinical oversight of the rotas to ensure resident doctors are meeting their curriculum requirements
• local induction to provide further orientation to fully equip resident doctors for their on-call duties.

Since the 2023 visit AIM has been monitored as an ISF 1 (minor concerns) through quarterly monitoring the learning environment meetings with the trust.

Due to ongoing concerns within AIM in relation to supervision, senior support and rota gaps and feedback contained in a LTHTr internal report a learner/educator review was arranged. The 2024 GMC NTS results also showed a change for geriatric medicine and as such was on the 2024 GMC Priority List due to changes in scores since the 2023 survey. The 2024 GMC NTS also showed lower scores in diabetes and endocrinology.

Who we met with

Learners:

• 7 resident doctors in geriatric medicine and diabetes and endocrinology
• 6 resident doctors in AIM and general surgery

Educators:

• 8 Consultants from Acute Internal Medicine including cardiology, geriatric medicine, gastroenterology, diabetes and endocrinology and the Medical Assessment Unit. Speciality Business Manager Medicine.
• We received apologies from one Consultant Chest Physician.

Education team:

• Director of Postgraduate Medical Education
• Deputy Director of Education
• Compliance Manager (Medical Education)

Review panel

• Professor Paul Baker, Deputy Postgraduate Dean, North West School of Foundation Training and Physician Associates and Education Quality Review Lead
• Dr Mumtaz Patel, Associate Postgraduate Dean, link Associate Dean for the trust
• Rowena Jackson, Lay Representative
• Paula Fletcher, Quality Support Manager
• Carole Aitken, Quality Coordinator

We would like to thank the medical education team and staff in the Health Academy for facilitating the sessions with resident doctors and their supervisors and for making the visiting team from the deanery feel very welcome.   

Review findings

Domain 1 Learning Environment and Culture

Handover

Handovers take place each morning and are led by the sister that day with consultant presence and were described as functional. Some resident doctors felt that how effective weekend on call handovers were depended on who was leading the handover.

Resident doctors in gastroenterology said they had a good handover and are supported by seniors.

In general surgery the panel heard that a RMO covers overnight and there is no senior in the morning, so they go to find the ward clerk.

Rota management

Resident doctors in AIM described the rota team as “reactive” rather than “proactive” as they are aware there are gaps in advance, but they are not planned for. A foundation doctor in gastroenterology told the panel of staffing issues whereby it was just themselves and a locum doctor. The foundation year 2 doctor was on call, and were being asked questions that should have been directed to a senior doctor to deal with. They had no one to escalate to. The panel heard that there has not been any impact to patient safety as a result. Resident doctors explained that there is a process to follow regarding leave and resident doctors can email the rota coordinator.

Raising concerns

There was variable awareness of the Guardian of Safe Working amongst resident doctors in AIM when asked how would they escalate concerns. Some AIM foundation doctors had completed Datix reports and had feedback from these.

In general surgery the panel heard that sometimes Datix is used as a threat rather than a tool to improve patient care. This issue has been raised with surgical consultants.

Educational resources

The panel heard that educational resources at Chorley are good.

Audit/quality improvement

Foundation doctors in general surgery have difficulty in getting support with quality improvement projects. There is evidence of resident doctors in surgery completing these on their own initiative as they have an interest.

Gastroenterology was described as “good” with a proactive registrar and other resident doctors in AIM said they receive regular support in conducting quality improvement projects.

AIM resident doctors said they get enough work placed based assessments (WBAs). In general surgery some foundation doctors said they ask the doctor on call when they are on shift in Preston to sign off their WBAs.

Exception reporting

All doctors the panel met in AIM had exception reported, they explained that exception reports previously went to their clinical supervisor but now go to medical staffing. They said this is better as previously some resident doctors felt they were pressured not to exception report and were interrogated regarding the hours reported and asked if they had a problem with prioritisation.

Equipment

The panel heard there is a lack of relevant services and equipment in the hospital for example non-invasive ventilation (NIV). Resident doctors described the difficulties they have requesting scans overnight as only registrar level doctors can request a CT scan for example. 

The panel heard from a resident doctor in AIM that some wards do not have advanced life support defibrillators, i.e. those with added functions such as cardioversion and pacing. The panel heard an example whereby a resident doctor was treating a patient in a pre-cardiac arrest state, with an arrhythmia treatable by cardioversion. Cardioversion could have prevented deterioration to cardiac arrest, but the crash trolley had a community defibrillator, i.e. one which can only defibrillate, being designed for use by the public. Therefore, they were unable to cardiovert or pace the patient in an attempt to prevent deterioration. In this instance no harm came to the patient.

The panel raised this with supervisors who confirmed that there are advanced ones in the trust and training is provided.

This was fed back to the Director of Postgraduate Medical Education at the end of the review as an immediate patient safety concern. Please see immediate mandatory requirements section on page 14.

Cross cover

Resident doctors were asked about consultant cross cover. The panel heard that when one of the geriatric medicine consultants was on leave for a week cover was provided from another ward and the covering consultant did 2 ward rounds. Consultant cross cover was also provided in D&E when a consultant was on compassionate leave.

Domain 2 Educational governance and commitment to quality

Equality, Diversity and Inclusion (EDI)

The panel did not hear of any issues in relation to EDI when speaking with resident doctors in D&E and geriatric medicine. Resident doctors said that they knew how to raise any issues and felt supported to do so.

A foundation doctor in AIM provided an example involving an international medical graduate (IMG) they had witnessed. The panel heard that the IMG was asking several questions regarding sending a discharge letter via email. The IMG doctor was discouraged from asking questions of clarity which the foundation doctor felt was not acceptable as the IMG doctor was new to the NHS. 

Domain 3 Developing and supporting learners

Induction

When asked about their induction most resident doctors had received a trust induction and were allocated time to complete their mandatory training and this included shadowing days for foundation doctors. The panel heard from a resident doctor that at their local induction there was limited welfare and support information provided for doctors that are breastfeeding. There are breast feeding facilities at Chorley for resident doctors and the doctor that raised this offered to speak at trust induction to raise awareness.  

The panel heard that resident doctors experience of local induction was variable. The panel heard that the geriatric medicine induction was good with a full introduction to Chorley, with an opportunity to meet the consultants. There was an example heard from a resident doctor who did not receive an induction as they started at Chorley on call.

Resident doctors in AIM and general surgery experience of local induction were not as positive as those in geriatric medicine and diabetes and endocrinology (D&E). The panel heard that local induction in surgery was “non-existent”.

Foundation doctors confirmed they receive a weekly job plan.

Resident doctors in geriatric medicine and D&E had an information sheet about on-calls with an explanation of the different bleeps.

Teaching and learning opportunities

Foundation doctors in geriatric medicine and diabetes and endocrinology said they have opportunities to learn and are part of the ward rounds. They said they have the chance to see patients and discuss them with seniors. They are encouraged to ask questions and to undertake procedures that build their confidence. Resident doctors did not stipulate which geriatric medicine or diabetes and endocrinology ward they were referring to.

IMT doctors said they did not have any problems getting to clinic and commented that ward rounds are good. Some foundation doctors said they felt unable to leave the ward to go to clinic and felt they should stay on the ward and let the registrar go to clinic, but said there are plenty of opportunities to go. In geriatric medicine the panel heard there were difficulties in leaving the ward to attend clinic as there is no one to cover the ward.

D&E was felt by resident doctors to be better staffed compared to other specialties. The panel heard that on call shifts are often short staffed and when it is just the registrar and themselves nights can be busy. When Chorley is busy overnight patients are sometimes diverted to the Royal Preston Hospital.  

Foundation doctors in AIM explained they had difficulty attending teaching on the MAU on Tuesday afternoons as they felt under pressure to get everything done by 12.30pm. They explained that the gap is not filled and are worried about the ward.

Supervision

Resident doctors in geriatric medicine and D&E said they are well supported and supervised and can access senior support when required. Resident doctors did not stipulate which geriatric medicine or D&E ward they were referring to.

The panel heard from a foundation doctor who explained that after the ward round they are often the only doctor on the ward as the registrar is seeing referrals. The panel heard that the usual quota of doctors is up to 3, the foundation doctors said they felt 2 doctors is safe and that a senior doctor is contactable via WhatsApp. The panel heard of an instance whereby their registrar was scrubbed in at Preston, there was no consultant available, and the foundation doctor was on their own.

The lay representative asked the resident doctors if this was a new issue. Some of the foundation doctors said they had heard about this issue from previous foundation doctors, and this had been going on for over a year.

From local intelligence and from contact with foundation doctors in general surgery, they are not receiving direct supervision as required by the GMC, local induction or support with QI projects. Post operative care and discharge seem to be wholly the responsibility of the resident doctor. 

Foundation doctors experience seems to largely consist of undertaking educationally unproductive tasks and is pure service provision. For example, writing discharge summaries and prescribing analgesia. Foundation doctors in general surgery have expressed concern regarding lack of theatre and clinic time. An example provided included being bleeped in theatre to write a discharge letter which frustrated the consultant, so foundation doctors no longer try to get to theatre/clinic due to this. These issues were fed back as an immediate mandatory requirement.

Out of hours

The panel heard from resident doctors in AIM that when they are on the MAU out of hours there are difficulties with ward cover at weekends. One resident doctor said there have been times when they can be the only doctor covering the wards and the registrar is covering admissions. They also commented that discharge ward rounds at the weekends are “unmanageable” they explained a locum doctor undertakes this, and that doctor joins the ward cover for the rest of the hospital after lunch. The panel did not hear any examples of patient safety being affected.

Domain 5 Delivering Curricula and Assessments

Training experience  

The panel heard of examples of resident doctors in AIM feeling exposed and being pressured to make decisions that are outside of their competencies and above their seniority including

• Pressure from some nurses to make decisions to discharge patients
• When a foundation doctor refuses to make discharge decisions the tone of voice used by some nurses in response implies, they are not doing their job
• Asked to make decisions regarding end-of-life care and DNR patients as they are the only doctor on the ward as the registrar is on referrals

Recommendation of placement

Geriatric Medicine and D&E

The panel asked resident doctors in geriatric medicine and D&E if they would recommend their training at Chorley and South Ribble Hospital. 3 resident doctors said “yes”, and others were undecided.

When asked what the good things are about the hospital, responses included

• D&E is good for IMT doctors.
• It’s not as busy as Preston.
• No on call for foundation year 1 doctors.
• Good support for less than full time doctors.

When asked what they would like to see improve, responses included:

• More staffing.
• More support for doctors returning from maternity leave.

AIM and General Surgery

Resident doctors were asked if they would recommend their placement at Chorley and South Ribble. Resident doctors on the coronary care unit and respiratory specialities said “yes”. Other resident doctors in AIM and general surgery said “no”

When asked what the good things are about the hospital, responses included

• Good support on Hazelwood Ward (respiratory) good teaching and can learn a lot.

When asked what they would like to see improve, responses included:

• Not completing discharge summaries for patients, they have not seen
• Completion of less educationally unproductive tasks
• Proactive rota management to ensure gaps are covered. Absences are known weeks in advance but are regularly not covered. For example, a resident doctor in AIM said that they have had to find cover for themselves to be able to attend teaching.
• Suggestion to use surgical resident doctors at Chorley to review patients that are normally sent to Preston for surgical review    

Domain 4 Developing and Supporting Supervisors

The patch Associate Postgraduate Dean explained why the visit was taking place and asked supervisors if they felt supported, what works well for them and if structures worked for them.

Teaching experience

Supervisors explained that the MAU is very busy, and they try to involve resident doctors, but sometimes this is not possible due to how busy it is and therefore cannot achieve the level of teaching they want. Supervisors said they do release foundation year 1 doctors for teaching.

The panel heard that care is sometimes provided on the MAU corridor, but good clinical care is provided despite no increase in resources. A supervisor referred to the description of the MAU as “chaotic” in the LTHTr internal report and said if there are 50 patients in a space designed for 30 then it will be chaotic and commented that consultants work under a lot of stress.

Consultants explained they have a responsibility to clear the board and therefore are unable to let resident doctors take 2 hours to see a patient and they must make decisions quickly.

Rota

A cardiology consultant informed the panel that absences are predicted i.e. teaching and the rota team are informed over a month in advance of leave etc and on the day of the absence they are “scrambling” around contacting consultants asking to move doctors to cover rota gaps. For example, consultants regularly receive texts in the morning asking if they can spare staff. Consultants said predicted absences need to be better managed, although they did recognise that medical staffing are doing their best under difficult circumstances.  

In D&E the panel heard that they also see little of their middle grade doctors due to the reasons described by other supervisors. Most days the consultant has to ring medical staffing for cover.

Consultants felt the rota would be more effective if medical staffing was adequately staffed and if there was a rota coordinator based at Chorley. If the rota was more effective there would be fewer periods of time that middle grades would be unavailable. This issue was raised by consultants in the 2023 learner/educator review and a recommendation made for frequent clinical oversight of the rota. Some supervisors felt there was disparity between the Chorley and Preston sites and felt the trust should look at how resident doctors are shared out.

Job planning

When asked about their job plans some consultants felt they were not appropriate and commented that a lot of work has been done on job plans over the last few years. The panel heard from a MAU consultant who supervises between 8-9 resident doctors despite job plans being capped.

Educational role

When asked about consultant development consultants said that most educational events are held at Preston which they struggle to attend. The panel heard that Chorley consultants organise their own educational events.

Supervisors were asked how they felt as a consultant, do they feel integrated, part of a team, and part of one trust. An example provided from a supervisor was a colleague they have spoken to in haematology for over 10 years, they have never met. Some supervisors said it can be difficult to get an orthopaedic or general surgical opinion and difficult to get their patients to Preston. Therefore, this impacts on the experience of resident doctors.  

The panel heard that in gastroenterology there is a new clinical director who they felt is more inclusive. Some consultants felt that managers were not always visible.

Supervisors were asked about the availability of advanced life support defibrillators as raised by resident doctors. The panel heard that Chorley does have advanced life support defibrillators.

Supervisors explained that they see some of their resident doctors around 3 or 4 weeks in a placement as resident doctors can be on nights for 4 days, then time off, study days and zero days so it can be difficult to sign them off.

The panel lead informed supervisors that there will be an opportunity to submit a business case for additional foundation doctors.

Supervisors commented that resident doctors do not have a full understanding of the constraints and pressure that consultants are working under. This is reflected in some of the comments made in the LTHTr internal report.

Some supervisors said they are not always informed if it is their resident doctors first job in the NHS and sometimes, they are put on nights immediately which does not work well. They said this needs to be better managed. The panel chair said that international medical graduates (IMGs) are identified by the deanery, the trust are informed, and IMGs then received a regional induction. It may be that this information is not filtering down.

Supervisors were asked about support for mothers returning to work following maternity leave. Supervisors said they are supportive of resident doctors needs e.g. with caring responsibilities, or with young families. Supervisors were asked if breastfeeding rooms are available and replied that there are. Supervisors were asked if this information was provided ahead of resident doctors return to work/placement commencing. Supervisors were unsure.

Clinics

Supervisors in gastroenterology said it has not been fed back that resident doctors have had any problems leaving the ward to attend clinics. Some supervisors said there is a lot of pressure for foundation doctors to stay on the ward and therefore it can be difficult for them to attend clinics.

Support

Supervisors were asked how can they be better supported. They commented they would feel more supported if staffing levels were appropriate. Some said there is disparity in staffing levels between Preston and Chorley and Preston is staffed appropriately at all training levels. They said that Chorley should have 10-12 middle grade doctors but there are currently 5 and they are on the on-call rota, therefore there are lots of gaps that affect supervision. Consultants are called to cover gaps.

Supervisors acknowledged that although there are areas of feedback in the internal LTHTr report that are not in their gift as consultants to resolve some are for example working relationships between consultants, one consultant commented “that could be different”.

They also felt that the internal LTHTr internal report does not address the cause of much of the resident doctor feedback which is the lack of staffing, and some consultants felt that management were not taking their concerns seriously.

Areas that are working well

Areas for improvement

The immediate mandatory concerns were fed back to the trust on the day of the learner/educator review and an action plan was subsequently submitted.

Immediate mandatory requirements

Mandatory requirements

Recommendations

Report approval

Report completed by: Paula Fletcher, Quality Support Manager
Review lead: Professor Paul Baker, Deputy Postgraduate Dean North West School of Foundation Training and Physician Associates
Date approved by review lead: 21 February 2025

NHS England authorised signature: Dr Raghu Paranthaman, Deputy Postgraduate Dean
Date authorised: 25 February 2025

Final report submitted to organisation: 25 February 2025