Executive summary

The review panel is thankful to the trust for accommodating this review and for facilitating good attendance at each of the sessions.

The review panel was pleased to note doctors in postgraduate training (DPTs) had enjoyed their training experiences in gastrointestinal and musculoskeletal subspecialty clinical radiology teams. The department reportedly had some excellent educators who were very engaged with training and made a great effort to support DPTs.

However, these positive experiences were outweighed by reports of bullying, undermining, non-collegiate interactions and major cultural issues across the department, which severely impacted upon DPTs’ training experience and satisfaction with their placements. DPTs did not feel the department was psychologically safe to raise concerns. They expressed anxiety about continuing in their current posts and a strong desire to train elsewhere.

Both supervisors and DPTs partly attributed these cultural issues to an extremely high workload across the team and its impact upon consultants’ time for training and getting to know DPTs. Consultants’ remote working arrangements and the department’s space and facilities were also said to hinder the fostering of good working relationships, team building, collaboration and effective educational interactions between consultants and DPTs.

The review panel heard that some DPTs did not know who their named supervisors were and/or had not had any meetings with them. The review panel issued an Immediate Mandatory Requirement (IMR) to address this concern within five working days.

The local induction and teaching programmes were reportedly inadequate, with both led by DPTs rather than consultants. It was highlighted that the department’s local Training Programme Directors (TPDs) did not have sufficient administrative support, which hindered their ability to focus on training and teaching, and consultants’ job plans needed to be more aligned with the delivery of education.

In light of the team’s 10 consultant vacancies, the review panel was concerned as to whether there was a sufficient number of consultants in post to sustain the department’s workload and training requirements, and as to the workload DPTs were expected to undertake.

This report includes specific requirements for the Trust to take forward, in addition to the IMR, which will be reviewed by NHS England – London as part of the three-monthly action planning timeline.

Review overview

Background to the review

This Urgent Risk Review was initiated in response to negatively outlying 2024 General Medical Council (GMC) National Training Survey (NTS) results for the clinical radiology programme group at Northwick Park Hospital (NPH), reported for the following areas: overall satisfaction, clinical supervision, clinical supervision out of hours, reporting systems, teamwork, supportive environment, induction, educational governance, educational supervision, local teaching and study leave.

These results demonstrated a significant deterioration from the programme’s 2023 GMC NTS results, but a similar set of results to those reported in the 2021 and 2022 surveys indicating a persistent issue with quality and education in the radiology department. An education quality review was conducted by Health Education England (HEE, now NHS England) in March 2022 in response to the programme’s 2021 GMC NTS results. The March 2022 review generated several mandatory requirements around cultural issues (including tense relationships between DPTs and consultants), longstanding rota problems impacting training, a high workload, insufficient training for supervisors and concerns about the local TPD workload, amongst others. These requirements had all been closed at the time the 2024 GMC NTS results were published however the lack of sustained improvement in the GMC NTS was a cause for concern and hence this review.

The Trust provided the following evidence in preparation for this August 2024 review:

• Local Faculty Group (LFG) meeting minutes: August 2023 to July 2024
• Departmental Quality Improvement Project (QIP) information: 2023
• Breakdown of clinical and educational supervisors: 2023 – 2024
• Breakdown of learner groups in clinical radiology: July 2024
• Local teaching timetable and information: 2023 – 2024
• Trust induction feedback: August 2023 and February 2024
• Specialty training level one (ST1) to ST6 DPT work schedules: December 2023
• Freedom to Speak Up Guardian annual report: 2023 – 2024
• Guardian of Safe Working Hours annual report: 2023 – 2024
• On call rota summary: January 2024 – April 2025
• Radiology registrar feedback: December 2023
• Summary of complaints about clinical radiology learners: 2021 – 2024
• Summary of serious incidents and never events in clinical radiology: January 2023 – July 2024

This information was used by the review panel to formulate the key lines of enquiry for the review. The content of the review report and its conclusions are based solely on feedback received from review attendees. 

Who we met with

Learners

• 22 specialty training (ST) clinical radiology DPTs between ST1 and ST6

Educators

• 14 clinical and educational supervisors for clinical radiology

Educational and managerial leads

• Deputy Chief Executive
• Chief Medical Officer
• Medical Director
• Clinical Director
• Divisional Director
• Training Programme Directors (TPDs)
• Director of Medical Education (DME)
• Head of Medical Education
• Postgraduate Centre Manager
• Head of Imaging

Review Panel

• Education Quality Review Lead: Dr Richard Bogle, System Dean – North West London, NHS England – London
• Specialty Expert: Dr Samantha Chippington, Head of the London Specialty School of Clinical Radiology, NHS England – London
• Learner Representative: Dr Joseph Flexen, Clinical Radiology Learner Representative
• Lay Representative: Robert Hawker, Lay Representative
• NHS England Education Quality Representatives:
• Gemma Berry, Education Quality Coordinator, NHS England – London
• Agnieszka Grzesiak, Education Quality Officer (Observer), NHS England – London

Review findings

Upon publication of the 2024 GMC NTS results, the Trust’s DME took a very proactive approach by facilitating a deep dive focus group with clinical radiology DPTs at NPH to understand the drivers behind the negative survey results for their programme group. DPTs’ feedback was taken to educational and managerial leads and consultants for reflection and to discuss how to address their concerns. As a result, an action plan was reportedly co-designed with DPTs and was in the process of being implemented. The educational and clinical leads recognised that DPTs had not been provided with an optimal learning environment and expressed a willingness to foster positive change. This sentiment was shared by some of the supervisors in the department, who saw this review as a good opportunity to resolve some of the issues that had been affecting the department for several years.

The leads and DPTs highlighted a deep-seated culture of bullying and undermining in the department as a key overarching, systemic issue affecting the learning environment. Although all DPTs and consultants had been asked to sign a new ‘Charter for Trainer and Trainee Responsibilities and Relations’ produced by departmental leads, DPTs found that the poor behaviour of some consultants had persisted although it should be noted the Charter was still in the process of being implemented. DPTs were also aggrieved that they had not been involved in the design or content of the Charter, which included advise that they should refrain from using mobile telephones in clinical areas. This advice did not apply to staff other than DPTs. It was also unclear whether the Charter was to be implemented for all staff in the Department or just supervisors and DPTs. Supervisors told the review panel there had been issues around the professional standards of some DPTs, with some leaving shifts early without notifying their supervisors, or not dressing appropriately for meeting patients.

DPTs emphasised that the department had some excellent educators who were very engaged with training and made a great effort to support them. However, some consultants had spoken to DPTs in a hostile and dismissive manner, which made DPTs feel unwelcome from the beginning of their placements. DPTs deemed some consultants to be unapproachable. DPTs had also overheard consultants making what they perceived to be disparaging or belittling remarks about DPTs in open spaces, including comments about their examination results, the GMC NTS results and this education quality review.

DPTs reported that some consultants were unwilling or unable to support them in a timely manner to provide clinical supervision, if at all. DPTs had found some on-call consultants to be uncontactable out of hours, or when they did answer calls, there were reports of sarcastic or flippant comments about the enquiry. This made DPTs reluctant to call for help and compelled them to make clinical decisions at the limits of their competency and confidence. They did not want to highlight any gaps in their knowledge in case they became the subject of consultants’ gossip or derision.

Whilst some consultants were willing to assist DPTs with cases outside their field of subspecialty expertise, others told DPTs they should not be approaching them for help and to find someone else. DPTs were often unsure where to turn to for advice and found effective clinical supervision to be a matter of luck, depending on the day, and who was on site. Some DPTs told the review panel that the majority of their learning and support had come from the goodwill of more senior DPTs, as they perceived only a small number of consultants to be engaged with training and education.

The leads advised that a new escalation policy had now been shared with all DPTs, so they knew what to do if an out-of-hours consultant was not contactable.

DPTs highlighted the implications upon patient safety as a result of these experiences, as well as the burden of responsibility placed upon them through the lack of support and supervision they received from consultants. DPTs new to the department and/or specialty were particularly anxious and alarmed to hear of their peers’ experiences and how they might cope on their placements. They were very worried about their training prospects at NPH.

It was noted by the leads, DPTs and supervisors that consultants’ remote working arrangements which had been promoted during and since the COVID-19 pandemic had hindered the fostering of good working relationships, team building, collaboration and effective educational interactions between consultants and DPTs. Whilst the review panel heard that consultants in general found homeworking to be more productive than working on-site, there was recognition amongst the leads and supervisors that DPTs might feel there was not enough consultant presence and support in the department. Supervisors highlighted that a lack of workstations and space to sit alongside DPTs was detrimental to the facilitation of training and relationship-building.

DPTs said they were only familiar with around 10 per cent of the consultant body and interactions with them had been minimal. Similarly, supervisors said they did not know all of their consultant colleagues and there were few opportunities for them to get together to raise concerns or share feedback.

The leads advised that DPTs had been made aware of the design of consultant job plans to give them a better understanding of the consultant resource across the department and to bring the two groups closer together and manage mutual expectations. LFG meetings were also intended to foster better relationships amongst colleagues in the department and the review panel recognised that the most recent LFG meeting minutes were of a high quality. DPTs said, and the review panel found, that whilst the LFG meeting minutes look good on paper, they only felt able to discuss superficial matters during these meetings.

DPTs still did not feel a sense of psychological safety around raising concerns. They were worried about repercussions and retribution. Some DPTs reported being gossiped about by consultants after raising concerns. They also felt there had not been satisfactory conclusions to concerns they had raised in the past. In some cases, they had been made to feel like they were responsible for finding solutions to what were often systemic issues affecting patient safety, such as consultants not checking scans within 24 hours of DPTs initially reviewing them whilst working out of hours.

The leads perceived that in some scenarios, grievances reported by DPTs had been blown out of proportion because they had adopted a survival mentality, due to the culture and workload of the department. The leads advised that DPTs could report poor behaviour and escalate concerns to the Clinical Director, the Medical Director or their deputy, the Postgraduate Medical Education (PGME) team, the Freedom to Speak Up Guardian or their supervisors and TPDs. Whilst there was no shortage of people to whom DPT could raise concerns there and this was made clear to DPTs at their induction there was no hierarchy around who DPTs could approach and there was not an environment of psychological safety to promote a culture of openness and teamworking. Supervisors also informed the review panel that a consultant had recently been tasked with facilitating feedback sessions with DPTs to discuss their concerns, but that DPT engagement and attendance had been minimal. DPTs said they had only recently been made aware that they could escalate concerns to the PGME team or colleagues outside of the department.

The leads, DPTs and supervisors partly attributed the department’s cultural issues to an extremely high workload and its impact upon consultants’ time for training and getting to know DPTs. The review panel heard that across the Trust’s sites, the clinical radiology service currently conducted around 14,000 studies per week (one million studies per year), which represented an increase of 40 per cent in the past two years. This had led to members of the team feeling overwhelmed, struggling with low morale and disempowered to make improvements. The consultant body was also currently carrying 10 vacancies and yet the Trust was due to open a new community diagnostic centre in the coming year, requiring eight clinical radiology consultant posts.

DPTs recognised that those consultants who were supportive and engaged with education shouldered the workload burden of training from other consultants. DPTs felt there was a limit to what these consultants could be expected to cover on behalf of the consultant body. DPTs suggested there were a large number of consultants who expressed a desire to deliver more training but did not have the time or capacity to do so.

The review panel heard that since Summer 2024, clinical radiology reporting for NPH began to be outsourced from 10.00pm – 9.00am each night, to alleviate DPTs’ out of hours workload and rota pattern. However, around the same time, the department took on the workload of Ealing Hospital and DPTs were rostered to work more consecutive 13-hour shifts, which led them to feel burnt out. The leads said DPTs’ feedback on this had since been acted upon and their work schedules now included extra zero days. DPTs said they had been asking for this change for a year, but it was only put into effect when this review was arranged, and they were still struggling with exhaustion from long days and a heavy workload, which they considered to be a potential patient safety issue. Supervisors told the review panel they had asked for outsourcing to start from 7.00pm (instead of 10.00pm) and to implement additional zero days for DPTs sooner but they had been met with resistance by Trust management, despite concerns being raised with the Guardian of Safe Working Hours. Supervisors recognised that further changes to the rota were needed to make it more manageable for DPTs. It was reported that an openness and discussion around change had only been accepted once the department had known that this review was to be undertaken.

Whilst some DPTs thought that an increase in outsourcing would release pressure on consultants to allow more time for training, others believed that the poor culture of the department and some consultants’ negative attitudes towards DPTs was so entrenched that it would not make much difference to their training experience.

DPTs were concerned about the volume of cases on their solo acute ultrasound lists, which usually had 12 to 14 inpatients and outpatients booked onto them, regardless of their training grade. DPTs found these lists to be exhausting and expressed concern that patients they met with at the end of lists did not receive optimal care for this reason, nor did they have sufficient time or supervision to obtain advice on cases they were unsure about. Musculoskeletal patients were also sometimes booked in at short notice, but they were supposed to be seen by consultants. DPTs said they had asked clinic coordinators and consultants for the case numbers to be reduced but were told that they had to meet certain targets.

Supervisors also reported feeling under pressure to meet targets, which diverted their attention from teaching. They suggested further outsourcing was necessary to sustain the department.

Rota coordination was currently undertaken by a DPT with support from a consultant. The DPT was assigned one session per week for this task, but it was found to be very burdensome and time-consuming throughout the working week. They were sometimes contacted whilst on leave to deal with rota queries.

DPTs found their educational supervision to be variable, with some consultants offering very good support, whilst others were disengaged. Some DPTs did not know who their named supervisors were and/or had not had any meetings with them.

Some educational supervisors had reportedly told the leads that they were not sure what they were supposed to be doing with the DPTs allocated to them. The leads had recently decided to review the current group of educational supervisors, ensuring only those actively interested in education were assigned DPTs and offered training to deliver their duties effectively. Supervisors felt that their consultant job plans needed to be more aligned to the delivery of education. The review panel also heard that the department’s TPDs did not have sufficient administrative support, which hindered their ability to focus on training and teaching. The DME was now working with the TPDs and educational supervisors to redesign and strengthen the department’s educational governance structure. Supervisors recognised that communication between DPTs and educational supervisors needed to improve and DPTs should be made to feel more comfortable about approaching their supervisors when needed. The review panel felt there needed to be a distinction between TPD roles and the Educational Lead/College Tutor, with a designated lead for Radiology training responsible for the quality of the training in the department, running the LFGs and ensuring educational governance processes are in place.

DPTs told the review panel that ST3 and ST4 DPTs led the local induction programme and DPTs did not have any interaction with consultants during this time. Whilst DPTs were allocated to clinical areas during their induction, they did not have specific colleagues to meet with and in some cases, had been met with hostility by consultants when proactively introducing themselves.

DPTs found the local induction programme to be unprofessional and not fit for purpose. They reported a lack of clarity around what was expected of them and what they needed to achieve during their placements. They said they were not provided with an induction handbook or any guidance documents, although supervisors said they were sent an induction pack before they started. The leads advised that in future, they would be adopting the induction templates DPTs found to be most effective and were taking advice from the London Specialty School of Clinical Radiology about how to clearly set out required competencies and reporting targets, for the benefit of both DPTs and supervisors.

The local teaching programme was coordinated by DPTs, but they reportedly struggled to recruit consultants to lead sessions. Sessions were poorly attended due to being held at lunchtimes. DPTs said they did not feel able to ask consultants to cover them while they attended. The TPDs were now reportedly leading on the redesign of the programme, ensuring it was delivered by consultants and was mapped to the curriculum. It was highlighted that whilst teaching was included in consultants’ supporting professional activities (SPA) allocation, their clinical work often eroded this time. The TPDs planned to document teaching within consultants’ job plans so that it did not clash with clinical commitments. A plan for local teaching sessions to be conducted from 8.00am – 9.00am on Tuesdays, Wednesdays and Thursdays had reportedly been posed to DPTs but needed to be discussed at upcoming LFG meetings. The leads recognised that the timings would not work for everyone but that DPTs could join via MS Teams and clinical supervisors were being asked to support DPTs to attend teaching whenever possible. DPTs would be paid for their out of hours attendance.

Study leave was highlighted by the leads as an area of frustration for DPTs due to an overly complicated process around reimbursement. This problem was not specific to radiology and the system used to support this process was being changed across the Trust, which the leads hoped would make a significant improvement.

Despite the wide variety of cases they could access at NPH, many DPTs expressed a strong desire to train elsewhere and questioned the suitability of the department for training and education. As cultural and training issues had persisted since HEE’s review in 2022, DPTs were concerned that any action now taken by the Trust might only be reactionary and short-term, not necessarily driven by a genuine willingness to make lasting improvements. They were worried that this review would stoke greater tensions between DPTs and consultants, and about any further disruption that may be placed upon their training by activities to address the issues raised. In contrast, supervisors believed the 2024 GMC NTS results and this review had been a real ‘wake-up call’ to consultants and management and confirmed they were making concerted efforts to effect positive change, but more time and resources were needed.

Areas that are working well

Areas for improvement

Immediate mandatory requirements

Trust response to IMR 22 August 2024: ‘Clinical Radiology TPDs have liaised with all trainees in post (except for those on parental leave) and confirmed their educational supervisors, as well as ensured that meetings have been scheduled. There are a couple of consultants and registrars on leave but TPDs have been in contact with them all and meetings will be arranged on their return. Attached list outlines the meeting schedule. We can confirm that meetings until and including 22 August have taken place.’

Mandatory requirements

Recommendations

Report approval

Report completed by: Gemma Berry, Education Quality Coordinator, NHS England – London
Review lead: Dr Richard Bogle, System Dean – North West London, NHS England – London
Date approved by review lead: 4 September 2024

NHS England authorised signature: Dr Elizabeth Carty, Interim Local Postgraduate Dean, NHS England – London
Date authorised: 2 October 2024

Final report submitted to organisation: 3 October 2024 

Publication reference: PRN01548