Executive summary

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

The two open requirements for Neurosurgery are on the General Medical Council (GMC) Quality Reporting System at Intensive Support Framework (ISF) Level 2 and the GMC were in attendance to observe the meeting.

The trust provided an excellent update around the two open requirements; interdepartmental behaviour and workload with specific reference to the cauda equina pathway (see page 4).

This year’s GMC National Training Survey (NTS) data is not currently available, but the National Education and Training Survey (NETS) has changed from red to pink and white. There is only one free text comment for Neurosurgery relating to the cauda equina pathway which was very reassuring.

Intensive mediation has taken place over the last year and working relationships have improved significantly. The trust was commended on this improvement (see page 4 and 6).

A substantial investment in the workforce and NHS England acknowledged the size of this expansion (see page 7).

NHS England propose to close the culture requirement following sight of the Foundation Year (FY) survey and de-escalate the workload requirement to ISF Level 1 pending the 2025 NTS survey and any other intelligence.

Dr Odedra was thanked for all the effort taken to continue to resolve the issues in Neurosurgery and NHS England will write formally to acknowledge all the work that has been done. Support would be offered with handovers to the new DME where needed.

Review overview

Background to the review

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

• 2023-24 Annual Guardian of Safe Working Hours (GOSWH) Report
• 2025 Quality Account GOWSH Report
• 2025 Neurosurgery Open Requirements Progress Report – March
• 2024 NETS Neurosurgery
• 2024 GMC NTS Neurosurgery – Programme Level
• 2025 Thank you email from Resident Doctors

Who we met with

Director of Medical and Dental Education and Associate Medical Director

Medical Education Manager

Deputy Director of Medical and Dental Education

General Manager, Chief Medical Officer’s Team

Review panel

• Education Quality Review Lead, Jon Hossain, Deputy Postgraduate Dean (Chair)
• Education Quality Representative: Muzzammil Nusrath, Associate Dean
• Speciality Expert: Nandan Haldipur, Head of School (HOS) for Surgery
• Speciality Expert: Nick Phillips, Training Programme Director (TPD) and National Clinical Lead for Neurosurgery
• Education Quality Representative: Joanne Seddon, Quality Support Manager
• GMC Representative: Robin Benstead, Principal Manager, Education Standards Department (Observing)
• GMC Representative: Sarah McCourt, Quality Assurance Programme Manager, Education Standards Department (Observing)
• Supporting Role, Michele Hannon, Quality Administrator

Review findings

Learning environment and culture – Neurosurgery open requirements

21/0020 – Neurosurgical trainees expressed concerns about the nature of teamwork with the Emergency department.

A significant amount of time and effort has been given to address the issues raised by the Neurosurgery resident doctors including mediation, exploratory conversations, and a complete workforce plan for parts of the wider team.

The historical issues date back thirteen years when the Orthopaedic Spinal Surgery department joined the Neurosciences department with no significant expansion in the workforce, which led to a division in responsibilities and was a key factor in the relationship issues in the department.

The trust is happy to report that following the intensive mediation event last year that working relationships have improved significantly.

There is evidence of this including good collaboration in the team e.g. engagement from both parties regarding job adverts for more Spinal Surgery consultants and a strict behavioural code which all have agreed to and is enforced.

The trust has conducted a survey of Neurosurgery resident doctors about culture, experience of Neurosurgery including training, and experience of Spinal surgery and relationships and there was a positive trend in responses.

They also asked about experience of working with Accident and Emergency (A&E) which relates to the second open requirement and although there are mixed reports, this is moving in the right direction and the free text comments reflect this.

Induction responses can be skewed by resident doctors responding historically if they completed the induction numerous years ago.

Mediation

The trust advised that the mediation was internally funded with an external company that took place in October 2024.

There was a launch meeting to set the rules, 1:1 meeting with staff and a 2-day event with selected individuals which included a representation of resident doctors.

Although details could not be shared, all issues were aired, and discussed, and staff were encouraged to agree to a behavioural code.

NHS England stated that changing culture was very difficult and queried what were the themes of the code as an example of good practice.

The trust said that this was around expectations and areas they wanted to see progress on e.g. attitudes. If they witnessed a deviation from acceptable behaviour this would be challenged, and it is built in that this needs to be reviewed monthly to see if it is being adhered to.

The result was a relief in clarifying issues that had been voiced, some were not true/exaggerated/misrepresented, and this had a very positive effect.

The trust advised they were not aware of any backsliding at all. There have been no escalated issues and communication from the TPD, the Clinical Director and others is positive.

The TPD advised that attrition was still improving, and for the first time they had a joint discussion around recruitment for the vacancy in Spinal Surgery should be. a Neurosurgeon with an interest in Spines or an Orthopaedic Spinal surgeon with an interest in Neuroscience.

There are some spontaneous social arrangements There is a joint handover every morning with all the team, so they do see each other regularly.

If there is unacceptable behaviour, they have courageous conversations in private and escalation but there has not been a need for this.

21/0021 – Perceived culture of bullying and discrimination within the Orthopaedic Spinal department. Neurosurgical trainees have reported that they are not receiving adequate educational opportunities.

There are patient pathway issues in A&E and a disconnect between Neurosurgery and Neuroscience. A patient with a head injury not for active Neurosurgical care would not come to Leeds if from outside or if they were at St James they would not necessarily come into the Neurosurgical bed base. However, if they come into Leeds General Infirmary (LGI) they will be admitted to the Neurosurgery bed base which is a tertiary centre and is the cause of the issues.

There are some issues with the A&E back pain pathway around access to imaging resulting in challenges in Radiology.

There is tension with A&E and Neurosurgery resident doctors, and a disconnect around the workforce.

Now the culture issue has been addressed they need to look at what can be done to get A&E and Neurosurgery to work together more effectively. Richard Baker has been involved in this; getting patients the right care, in the right place, at the right time.

The survey results describe challenges about patients in the bed base, but some get on with the A&E team and some do not, but fundamentally it is still an issue around the patient pathway which needs to be explored further, and which has been going on a long time.

Neurosurgery is a regional speciality that serves seven acute trusts to look after Neurosurgery referrals.

Four to five Neurosurgery patients on average each day are admitted with life threatening conditions to triage and manage beds so it can be viewed that they are protective of their space/elitist which can cause tension with the A&E department.

Few forced admissions are cranial, but there is a massive volume of spinal which should be on the Musculo-Skeletal (MSK) pathway, and they should not be admitting people with back pain.

Forced admission is a trust policy whereby they can admit if an assessment is done in primary care but often the assessment has never been done so patients are coming into Neurosurgery with no assessment and flood the beds.

LTHT are the only unit that has not implemented the cauda equina ‘Getting It Right First Time (GIRFT) pathway which has been implemented by every Royal College Radiology and Emergency Department.

They have tried to implement various aspects, but talks are currently stalled, and this was not help previously by the Radiologists’ access to scanning, but this has improved.

Workforce expansion

NHS England queried the details of the increase in workforce and investment in foundation and middle grades.

The trust stated that previously Neurosurgery had a well-established workforce of FY2, and core and Neurosurgery run though with the Postgraduate Doctors in Training (PGDiT) supported by more senior resident doctors until they are able do on-call.

Spinal did not have lot of PGDiT so appointed fellows and out of hours Spinal had two FY doctors from out of hours Orthopaedics.

Having a Spinal workforce was very important as they did not get the budget resource when they came across 12 years ago.

They looked at a 3–4-year plan for foundation expansion and Trauma and Orthopaedics (T&O) expansion of middle grades.

The trust took 24 foundation doctors from the NHS England FY expansion which included 8 for the entire Spinal rota and the thank you email is from the outgoing FY doctors in Spines.

This is a small group so if they have an issue, they may use recurring answers despite efforts to address this, but it has taken huge amounts of time, effort and money to resolve the issues, particularly addressing workload concerns in the department.

The Deanery supported discussions with the Director of Medical Education (DME), the TPD, the training lead for Spinal Surgery and sector tutor for Orthopaedics regarding an optimum workforce solution without impacting Neurosurgery, which was pursued.

They were able to generate an entire rota of Foundation Year (FY) doctors in Spinal Surgery and have received a positive thank you email from the FY doctors about the excellent quality of the training received.

The trust also instigated a middle grade rota for Spinal Surgery, supporting the FY doctors and Spinal on call for consultants, which has also been successful.

The TPD confirmed adequate exposure to learning opportunities both in and out of hours.

There have been real improvements in culture and the DME will share the FY survey, which demonstrates this.

With the year-on-year improvement of the NTS scores, it was advised the requirement could be de-escalated as there has never been an Annual Review of Competency Progression (ARCP) issue and when the resident doctors were asked if they wanted to move from the unit, they said they valued their wide –ranging experience at the trust and declined.

The TPD thought this was a very fair and accurate representation of the culture in Spinal Surgery and Neurosurgery and advised that there is no real division, and the mediation was very valuable and worked amazingly well. Magnus Harrison was thanked for funding the mediation and driving it forward.

NHS England wanted to acknowledge the size of the investment, and this has improved the training experience for all resident doctors.

PGDiT see the triage of cauda equina as poor training experience due to the unfiltered triage, but they have very good, well trained resident doctors with an excellent record for passing exams first time.

NHS England stated that one of the previous comments was that workload was depriving resident doctors of learning opportunities in theatre.

The TPD advised that they nearly all have full logbooks before Senior Trainee Year 7 (ST7) and then do a fellowship in their last year, ST8.

This year the GMC NTS comment is relating to the Emergency Department being dominant within the hospital. In Neurosurgery there were two issues, and NHS England would need to see the evidence as it is too early for the GMC survey.

NHS England acknowledged the strong approach the trust has taken to tackle cultural concerns, but it would be important to have sight of the survey information from Foundation doctors to look to close the culture requirement.

Workload has been red the longest and whilst the trust has discussed positive outcomes in logbooks and ARCPs, NHS England will need to review the NTS workload score. It was agreed to de-escalate the open requirement to ISF1 due to the progress made and monitor this until we get the NTS data.

The trust felt this was fair and are happy to share the survey. They acknowledge that workload score is still quite low, but they have been heartened that there has been year on year improvement.

NHS England cannot tell the trust how to manage the pathway but with GIRFT there is a push for productivity, and we need to make sure that the system is not detrimental to training and resident doctors are all very happy apart from this one issue.

The trust highlighted the low NETS response rate of five and NHS England said this was concerning and would welcome support of the trust to encourage uptake in the next survey in the autumn.

GMC priority list

• NHS England stated that Geriatric medicine at Leeds is on the priority list and the plan was to monitor this and on sense checking it is found to be foundation doctors at LGI in Orthogeriatrics.
• The trust said that none of the foundation doctors at LGI belong to Geriatrics, so they expanded Geriatric Medicine, but it was hard to decern which group this is.
• NHS England said that this may be an entry error, and they are in T&O.
• T&O has been talked about already with the rota changes and letter from FY1, we just need to monitor this.
• The trust said that exception reporting from T&O has dropped and by putting more FY doctors into Spines has meant that there are two FY doctors covering Spines out of hours so there were more T&O resident doctors looking after fewer patients. It is hoped that this will be reflected in the NTS.
• The trust was unsure if Neurology reflected the tertiary centre, workload or the workload on Stroke or whether it is Neurology.
• The DME met with the Neurologists, and the big issue was about undifferentiated admission of headaches, therefore a pathway was developed and effectively patients go to St James to the medics.
• The Neurologists put on extra clinics which increased exposure, and they have admission avoidance, which is working well, and they have not had much challenge or exception reports.
• The trust devised a Stroke General Internal Medicine (GIM) pathway and LTHT has funded six posts for provision but also to develop a talent pipeline. Neurologist do see some Stroke as part of the curriculum so this will help.  

Areas that are working well

A significant issue in Neurology was undifferentiated admission of headaches, the team developed a pathway and effectively patients go to St James to the medics. The Neurologists put on extra clinics which increased exposure, and they have an admission avoidance approach, which is working well. There has not been much challenge or exception reports.

The trust devised a Stroke General Internal Medicine (GIM) pathway and LTHT has funded six Consultant? posts for provision but also to develop a talent pipeline. Neurologists do see some Stroke as part of the curriculum so this will help. 

Good practice

Development of a trust behavioural code – This was around expectations and areas the trust wanted to see progress on e.g. attitudes. If they witnessed a deviation from acceptable behaviour this would be challenged, and it is built in that this needs to be reviewed monthly to see if it is being adhered to.

Areas for improvement  

Mandatory requirements  

Report approval

Report completed by: Joanne Seddon, Quality Support Manager
Review lead: Jon Hossain, Deputy Postgraduate Dean
Date approved by review lead: 5 June 2025

NHS England authorised signature: Jon Hossain, Deputy Postgraduate Dean
Date authorised: 16 June 2025
Final report submitted to organisation: 9 July 2025