Executive Summary

The primary purpose of the Monitoring the Learning Environment (MLE) meeting is to review the open requirements in Radiology, Neurosurgery and Immunology.

• LTHT continue to be engaged but there are still issues outstanding in Radiology. It is hoped that the new Clinical Director (CD) can make progress. It was reassuring that the General Medical Council (GMC) National Training Survey (NTS) scores have improved.
• Developments in Radiology including funding of a Radiology Clinical Fellow on some evening shifts is positive and the Director of Medical Education (DME) has been invested and helpful in exploring different options.
• The Radiology requirement will remain open for local monitoring and particularly in relation to out of hours supervision.
• The issues in Neurosurgery are long standing. The source of the issue is relationships within the Spinal Service who come from different specialties, namely Neurosurgery and Orthopaedics. The trust informed the visiting team that external mediation between the two groups has taken place and is progressing well.
• The requirement in Neurosurgery will remain open, with local monitoring. The Quality team in NHS England will receive an update from the DME on progress. With this being a longstanding issue, it is recognised that progress may take time to be demonstrated.
• The requirement in Clinical Immunology relating to the training of Clinical Scientists is in a position to be closed. The trust provided information on the steps they have taken to provide training. This is envisaged to restart in September 2025. The requirement can be formally closed when accreditation is confirmed.
• The trust provided helpful updates on the General Medical Council National Training Survey (GMC NTS) triple red outliers and concerns in Neurosurgery (see pages 6, 7, 9 and 10) and this will be fed back to the GMC.
• The trust will provide updates to the open requirements in Radiology and Neurosurgery in six months’ time.

Review overview

Background to the review

Monitoring the Learning Environment (MLE) meetings are undertaken to ensure that quality risks are managed effectively, and notable/good practice is identified and shared across the region, building on, and strengthening relationships with the organisation.

Evidence:

• 2023 National Education and Training Survey (NETS) highlights
• 2024 General Medical Council National Training Survey (GMC NTS) Neurosurgery data
• 2024 GMC NTS Clinical Radiology data
• 2024 GMC NTS multiple outliers
• 2024 Trust Self-Assessment (SA)
• 2024 GMC NTS scores and ranks
• 2024 Practice Assessment Record and Evaluation (PARE) reports
• 2024 Leeds Teaching Hospital Trust (LTHT) on-call feedback (September)
• 2024 GMC NTS survey summary
• 2024 GMC NTS bullying and undermining comments
• 2024 GMC NTS priority list – triple reds
• 2023 Guardian of Safe Working Hours (GOSWH) report – May – December
• 2023-24 GOSWH annual report
• 2024 LTHT Senior Leader Engagement (SLE) Quality interventions review report
• 2024 Quality open requirements detailed report

Who we met with

Education team

• Director of Medical and Dental Education
• Deputy Director of Postgraduate Medical Education
• Medical Education Manager
• Guardian of Safe Working Hours
• Consultant Neurosurgeon
• Clinical Director for Radiology
• Chief Scientific Officer
• Deputy Director of Postgraduate Medical Education
• Head of NMAHP (Nursing Midwifery and Allied Health Professionals) Professional Development (Pre and Post Reg)
• Advanced Practice Lead            

Review panel

• Education Quality Lead, Jon Hossain, Deputy Postgraduate Dean
• Clinical Radiology Head of School, Rachel Hyland
• Nick Philips, Neurosurgery Training Programme Director (TPD)
• Speciality Expert, Emma Bowers, Healthcare Science STP (Scientist Training Programme) Training Programme Director, North East & Yorkshire
• Speciality Expert, Lyndsay Murden, Nursing and Midwifery (NM) and Allied Health Professions (AHP) Workforce Lead
• Education Quality Manager, Joanne Seddon, Quality Support Manager
• Admin, Michele Hannon, Quality Administrator

Review findings

Learning environment and culture – Radiology

• The GMC NTS overall shows a positive trend with overall satisfaction improved and clinical supervision out of hours has improved slightly.
• Feedback from the Postgraduate Doctors in Training (PDiT) in addition to the GMC survey has been obtained which has shown some areas of good practice and areas of improvement.
• Concern was raised by the Radiology General Managers that funding may be withdrawn for interactions introduced previously if these are not helping.
• Continued funding of the post Certificate of Completion of Training (CCT) Radiology Clinical Fellows on the evening shifts has been well received and has had a positive impact on workload, and this will hopefully continue.
• There is ongoing work looking at consultant input when on call, to increase supervision for resident doctors.
• A twilight shift rota has been worked up by a focus group involving tutors, PDiT and trainee representatives who suggested extending their hours to provide increased cover and capacity in the evenings, which will also ensure there is resilience in the rotas to maintain safe staffing. There is a cost associated with this and is currently being reviewed.
• The trust reported that historically sickness was previously low on medical rotas but is now in line with other staff groups. Workforce patterns have reflected this building additional capacity for resilience which nursing and other groups have established. 
• Out of hours (OOH) workload in Leeds is considerable and the main concern is OOH supervision, annually increasing workload and the increasing number of rota gaps.
• The trust is exploring outsourcing of out of hours reporting, but there are concerns around cost and that this may lead to additional workload due to re reporting of outsourced work. The trust has not come to a final decision on outsourcing.
• There is new leadership in LTHT with a new CD for Radiology.
• The trust agreed with the points made by NHS England; gaps are challenging to solve, and the previous CDs have not succeeded, but they acknowledge that they need to push on with this.
• There remains an issue with out of hours reporting of MSK scans, particularly at the weekend. The PDiT reported that they feel vulnerable.
• The trust is exploring solutions, which may include outsourcing.
• Improving the morale of the Consultants in Radiology will improve the morale of all the workforce.
• NHS England stressed the importance of morale and wellbeing.
• NHS England advised that the open requirement in Radiology can be kept under local monitoring but the main issue to be monitored is supervision.
• The Head of School of Radiology would like to continue to work with the CD in the same way that they had with the previous CD and thanked the DME on behalf of the PDiT.

Actions

• The requirement will remain open for local monitoring and particularly in relation to out of hours supervision.
• Head of School of Radiology to work closely with the new Clinical Director and produce a school action plan.
• Trust to provide progress update in six months’ time.

Learning Environment and Culture – Neurosurgery

• The issues are long standing and relate to the management of Cauda Equina Syndrome (CES), the relationship of the referral pathway from the Emergency Department (ED) and the internal relationships in the spinal team.
• There remain difficulties in adopting national pathways for the management of CES. The trust is working hard to use the multi-specialty assessment area as opposed to the ED. The ED is perceiving more unity within the spinal team. The Medical Director (MD) is committed to address the issues around the CES pathway.
• NHS England recognised the considerable investment that LTHT has made in staffing in the spinal team as an indication that they are addressing the issues. This includes Foundation expansion posts and Orthopaedic Registrar grade posts.
• The extra staff have meant that PDiT feel less pressured.
• NHS England informed the trust that they are in meetings with the GMC about the NTS scores and the areas that have been escalated to the GMC Quality reporting system. Robust evidence will need to be provided to the GMC to justify the continuation of local monitoring in Neurosurgery. Involvement of an external body, such as the regulator, is not without threat and may decrease the momentum that has currently been achieved.
• NHS England stated that the PDiT within Neurosurgery only have concerns in these two areas of their training. They are otherwise happy.
• With regards to any non-training grade doctors within LTHT, there would be a desire to bring them under the umbrella of the Annual Review of Competency Progression (ARCP) process within the school of surgery, but the current 30% reduction in programme support staff within NHS England means that there is no resource to deliver this.
• Despite the current and planned expansion in training posts, there is currently no increase in the allocated resource for training faculty or curriculum delivery. This is on the NHS England risk register.
• The trust informed NHS England that mediation had started two months before, so a narrative can be collected from the PDiT.
• The requirement is worded around relationships. The implementation of a patient pathway around CES is not within the remit of the requirement, but evidence can and should be collected.
• NHS England stated that they would feed back the following to the GMC concerning Neurosurgery:
  • The post expansion and investment
  • The improved GMC NTS scores
  • The external mediation

Actions

• Open requirements to remain as monitor locally.
• Trust to provide a progress update in six months’ time.
• Jon Hossain to feedback to the GMC.

Supporting and empowering learners – Clinical Immunology

• The trust is now in a much better position and are working towards regaining accreditation to enable them to provide training at Higher Specialist Scientist Training (HSST) consultant level.
• They are aiming to submit their HSST accreditation documentation to the National School for Healthcare Science (NSHCS) by the end of November 2024.
• Providing the accreditation application and the Expression of Interest for an HSST trainee are successful, it is expected that the first HSST learner will start September 2025.
• Once the HSST trainee is in post, they will be expected, as part of their training, to put infrastructure in place to regain accreditation with the NSHCS for level 7 training and then support level 7 learners from September 2026.
• The trust advised that they have recruited the last Immunologist, and the delay is with moving into a new laboratory which will be in the new year, but improvements will then be seen.

Action

• The open requirement to be closed following confirmation of accreditation. 

Trust update

• The trust advised that their focus was on Neurosurgery and Spines.
• They were looking at educator time and surveyed trainers around time to train and they were in a poor position so focussed significantly on engagement including the Medical Director of Workforce.
• Supervision training and International Medical Graduate (IMG) inductions have been well received.
• There is a Medical Education Manager (MEM) Wider Education Community which is beneficial.
• The DME personally has concern about Medical Associate Professions (MAP) relationships and has been informed by the university that they have paused the undergraduate Physicians Associate (PA) programme.
• This is not a reflection on the comments about PAs but to understand the narrative and regulation from the GMC.
• The trust explored how MAP roles mature and as it grows, it does so in a sustainable fashion alongside the other workforce.
• There are challenges with engagement of PDiT, which is an issue in all staff groups and the key is focussing on improvements.
• The Improving Work Lives communication was embraced and there is a working group with Human Resources (HR), which will hopefully translate to other staff groups.
• There is a greater focus on addressing operational challenges systematically and efficiently.
• The trust is doing well with rota management and there is a Standard Operating Procedure (SOP) in place for escalation of gaps.
• Trust expectations on working to deliver care is included in the operational induction.
• Training is needed on how this is addressed in a systematic way rather than additional mandatory training.
• The trust is keen to capitalise on opportunities and use training expansion to address a lot of the issues.
• Foundation expansion helped with Spines and Neurosurgery, and they are progressing with Trauma and Orthopaedics (T&O) and hopefully Geriatrics and the ED.
• NHS England acknowledged and thanked the trust on their uptake of extra posts. There is an expectation the trust will ask for more posts and are working nationally for future expansion.
• PAs were discussed at the last Quality meeting around training and future availability of jobs, and this has been escalated to the Regional Medical Director (RMD).
• PAs were well established, but it is different across the country and comments on social media demonstrated a lack of understanding of the workforce.
• The trust stated that there was a national review from Deloitte’s around payroll issues.
• The trust is using the term resident doctors and the contract is named resident doctors’ contract.

GMC NTS Triple Reds

The trust addressed the GMC NTS triple reds:

• Dermatology at Chapel Allerton – facilities are an issue as the site struggles for work and rest space. The new CD and General Manager are looking at the estate for all staffing groups and have identified spaces for use by resident doctors.
• Haematology – the complaints are around space, but they are in Bexley Wing Private Finance Initiative (PFI) and are unable to change anything. Haematology sits within the Oncology Clinical Assessment Unit (CAU) and PDiT cross cover. There is a challenge in terms of space and the unsuitability of the building due to a lack of ventilation and the cost of fixing the situation.
• The trust stated that pressures on workload for consultants is affecting supervision as everything needs checking by consultants until qualified which limits training.
• They are looking at outsourcing reporting and expanding consultant posts due to the curriculum in Hematopathology and negative feedback. This was being outsourced but has not been resolved and is back in house and the workload for the consultants has dramatically increased.
• Histopathology – the trust is working with the team to understand the decline in the GMC NTS.
• Infectious Diseases – the trust stated that this has been in decline and have discussed the issues. There are challenges in the consultant group, but this is being actively managed. This is a very busy speciality with a mix of Microbiology and Infectious Diseases. There are a lot of dual PDiT and the trust was surprised by the results as the Speciality Training Committee report was excellent for feedback.
• There are curriculum struggles with benchwork tasks, but they have created benchwork training and working with the Simulation lead to see if this can be solved with Simulation.
• Neurology is a challenging department which does not have a Training Programme Director (TPD) which is a big problem. Neurology PDiT work for other trusts but provide out of hours cover and there have been discussions around cross covering Stroke. A lot of work has taken place looking at rotas so PDiT get adequate rest and taking Headaches out of Neurology and there are more admissions avoidance clinics, so the trust is unsure why this is on the list.
• There was a triple red in facilities at the Leeds General Infirmary (LGI) site and the feedback drop was a surprise. The trust said that there had been a problem staffing the on-call rota due to PDiT CCT dates, but this has now been rectified.
• NHS England stated that Geriatric Medicine is showing at LGI, but it is at St James Hospital, so this is likely to be Orthogeriatric and Geriatric registrars on the LGI site.
• The trust added that Geriatric Medicine use senior PDiT to provide cover on the night rota at LGI, but training days are at St James’.
• The trust advised that the trust funded the stroke GIM curriculum and are funding six posts to improve medical input at LGI which feeds into this and advised that Geriatrics at LGI is a consultant led service.
• Ophthalmology – the trust advised that there were issues last year and they met with lead clinical trainer and training leads. 
• Reporting systems – the trust did not have any insight on this and have met with PDIT who informed them of the issues previously with local teaching. A lot of work has been done and there is now training on Tuesday and clinics finish early so hopefully this will improve.
• T&O rota and workload – the trust advised that this should now be fixed. They have taken 50% and given this to Spines and have set up a middle grade rota in Spines with three additional T&O posts plus one other so the source of Spines referrals should be fixed. 
• The bed base has been reduced and given to Neuroscience.
• The trust has received two Foundation year doctors to cover Spine’s patients so overall there are fewer patients, fewer referrals, and more doctors.

Action

• To feed back to the GMC via the NTS survey meetings.

Review of multi-professional learner and educator voice intelligence

NETS results

• NHS England advised that responses have been quite disappointing, and any support would be appreciated although improvements have been made for adult nursing in the previous year.
• The trust responded that NETS had been sent to learners on placement, but it is difficult to engage with them individually. The trust will discuss with the Practice Learning Facilitator (PLF) team so they can advertise and encourage engagement.

PARE

• NHS England fed back there have been lots of responses with 52% green, 43% amber and 4% red which included some comments about staff attitude towards learners.
• The trust stated that they work hard to engage with learners and to encourage them to complete PARE and maintain robust processes.
• The PLFs respond to feedback around clinical areas and actively reach out to learners and attend clinical areas to provide support.
• They are aware of staff attitudes, which arises due to exhaustion, with workload often in silver command and staff are overwhelmed, but this is being addressed with human factors learning offered to help deal with overload.
• Practice supervisors and assessors do not always have protected time for learners, so an educator strategy has been written to address time to support learners.
• PARE is on the NHS England risk register.

Safe Learning Environment Charter (SLEC) implementation

• NHS England queried if the trust had plans to implement the SLEC?
• The trust stated that the SLEC is being implemented in midwifery but not in adult and children due to staffing resources with people on maternity leave and currently recruiting to two PLF posts and it may take time until the team stabilises.
• NHS England added it was good that this was in hand and that this is a tool which most trusts find beneficial.

Recruitment staffing levels

• The trust stated that they had done very well with international recruitment vacancies during covid until last year.
• Due to improved staffing levels, the trust has successfully closed its vacancy gaps and can now ensure posts are available for local graduates instead of relying on international recruitment. While staffing levels are currently the most stable they have been, the trust remains committed to making further improvements.
• NHS England added that the Long-Term Workforce Plan includes expansion in adult and all nursing which will be challenging and queried where the trust was in terms of placement capacity.
• The trust stated that capacity has always been an issue in adult and children.
• All universities want to place learners in the Children’s in Leeds, but they work closely with the universities.
• There are three active universities and now an additional one which will push capacity further.
• Improvement has been seen where they have support to deal with capacity, but currently there are no active projects from NHS England, and they need a long-term strategy on how we inject support to keep up with capacity as currently this is reactive rather than proactive.

Guardian of Safe Working Hours (GOSWH) update

• The trust has recommended an escalation policy in some specialities for short notice gaps due to sickness where PDiT are covering two people’s jobs, resident to non-resident, and who takes ownership when this happens.
• The GOSWH has met with the MD and is working with CDs in those areas to work on this.
• It is hoped that in due course exception reporting in T&O will be better with the new rota which has recently gone live, and this will be evaluated in 6 months’ time.
• NHS England stated that we are required by the GMC to follow up patient safety comments and monitor locally Obstetrics and Gynaecology (O&G) on-call nights and Renal Medicine.
• The trust stated that the GOWSH escalation policy is the way forward for O&G.
• The trust added that consultant acting down has been addressed. PDiT are still expected contractually to cover short notice sickness but are not actively doing this and queried if there was anything on the good practice app on how this could be reinforced.
• In Renal Medicine there have been two patient safety comments about the outlier shift and managing referrals on the online portal.
• The trust recognised that workload for the outlier registrar was becoming untenable, and the rota was changed and there are now two registrars with positive feedback, so this has been addressed.

Any other business and next steps

• The trust queried the funding for three trust funded T&O posts. If the trust knows this is happening, they will not recruit but if not, they will put LEDs in.
• NHS England advised that this should come through the school and Jon Hossain will speak to the School of Surgery.
• NHS England stated that feedback on the Neurosurgery and Clinical Radiology issues was needed and suggested a progress meeting in six months’ time.
• The trust agreed to send progress updates, and a meeting will be held if needed.

Actions 

• Jon Hossain to discuss T&O funded posts with Nandan Haldipur.
• Trust to provide written updates on the Neurosurgery and Clinical Radiology open requirements in six months’ time.
• NHS England to arrange a further MLE meeting if needed.

Areas that are working well

• The trust stated that they had done very well with international recruitment vacancies.
• The Improving Work Lives communication was embraced and there is a working group with Human Resources (HR), which will hopefully translate to other staff groups.
• The trust is doing well with rota management and there is a Standard Operating Procedure (SOP) in place for escalation of gaps.

Good practice

Supporting learners on placement across all our professions

We have increased the support we give to learners, many of whom come into the organisation with additional support needs.  
 
A long-established Professional Support Team (PST) in Medical Education, which over the last few years has reached and advised colleagues in NHS England, allowing it to expand its support to trainees (based on the LTHT model). 

Learner voice

LTHT has a long tradition of listening to learners (we are a former finalist in the HSJ Awards). In Nursing and Midwifery and across AHPs and Medical we have regular learner forums; the Resident Doctor Body supports the Chief Registrar (we undertake weekly listening ward rounds to reach out to resident doctors) and we have introduced Professional Nurse Advocate sessions. 

Safe spaces

LTHT is committed to creating psychologically safe spaces for learners to feel able to speak up on a range of issues. We have created health and wellbeing champions as well as mental health first aiders who are embedded within the organisation and made up of colleagues from across professions/staff groups.

Innovative training/course development 

Flexible training and teaching; our pharmacy education team has developed flexible programmes that take less than full time training into account. Across all our professions, and notably in undergraduate Medical, we have expanded our range of teaching styles to enable us to meet the varied learning (small group / individual teaching, through simulation, on-line and near to peer teaching are among examples). This is in line with our commitment to improve the learner experience through adopting an andragogy-based approach to our programmes. We continue to request robust feedback, reviewing it to constantly make improvements to our programmes as a result.  

New/improved strategy or governance 

Learning, Education and Training (LET) Committee; the LET Committee, co-chaired by the Director of HR/OD and the Chief Medical Officer, is now in its sixth year. 
 
In LTHT, LET is a complex endeavour with more than 13 different professional groups, each with their own management and leadership processes.  
 
Through the LET Committee, we have brought all these together, enabling the smaller professional groups to have a greater voice.  
 
This is helping the trust to target investment and energy into areas where education and training has historically lagged.  
One of the central themes in the LET Strategy (2023) was the need to ‘level up’; to ensure that staff in all parts of the organisation get improved access to education and training.  

We have more robust measures and KPIs, and a dedicated group (the LET Contract & Strategy Group) concentrating on ensuring we deliver all aspects of the strategy. 

Formation of working group

To ensure robust reporting on issues raised by Improving Working Lives but expanded to further inform and implement changes to improve working lives of doctors and by application, to all staff groups. Chaired by Workforce MD and Deputy HR Director.

Trust funding

Pilot Stroke/GIM HST training program which will if successful provide a more robust workforce solution for the region to expand and deliver stroke services.

Report approval

Report completed by: Joanne Seddon, Quality Support Manager
Review lead: Jon Hossain
Date approved by review lead: 26 November 2024

NHS England authorised signature: Jon Hossain, Deputy Postgraduate Dean
Date authorised: 26 November 2024

Final report submitted to organisation: 18 December 2024