Executive summary

Due to the number of negative outliers in GMC survey results in 2023 and 2024, we scheduled a learner/educator review to speak to resident doctors and supervisors in plastic surgery at The Royal Manchester Children’s Hospital (RMCH)

The trust delivered a presentation at the start of the day and we fed back a brief summary to trust representatives at the end of the review.

Positive findings from the review included:

• Resident doctors said that there was a good range of opportunities and good supervision.
• The introduction of a trauma list & clinic for emergency paediatric cases
• An improved induction, with an induction to 3 sites covered (RMCH, Wythenshawe and Withington)
• Handovers were working well in general, apart from getting to a 5 pm handover from other sites.
• Positive working relationships in the department
• The recruitment of 2 chief residents for plastic surgery to provide more opportunities for 2 way feedback.

Areas to be improved included:

• Workforce demands and support for an ‘SHO’* tier were impacting on the capacity for higher tiers of resident doctors to access training opportunities, including cleft experience particularly.
• Induction for resident doctors new to the NHS – should be reviewed to ensure that it is appropriate for everybody including those new to the NHS.

We have also made recommendations to review recruitment processes, the culture and process relating to exception reporting, and explore comments made regarding anaesthetics.

*SHO was the terminology used by resident doctors and supervisors we met

Next steps

A senior leadership meeting to discuss the report will take place with the trust at a date to be arranged.

Review overview

Background to the review

The purpose of this visit was to review the training environment for resident doctors in plastic surgery at RMCH.  We were advised by the trust that plastic surgery resident doctors from Wythenshawe Hospital and The Christie also covered on call at RMCH.

Who we met with

Learners

• 9 resident doctors who had rotated to RMCH previously, or who were on a current rotation to RMCH, or based at other sites and covering on call at RMCH.

Educators

• 9 Consultants

Trust presentation and feedback session:

• Clinical Director for Burns and Plastics
• Specialty Lead for Burns and RMCH (Consultant)
• TSTL (Consultant)
• Resident Doctor (CST)
• Medical Director, Specialist Hospitals
• Director of Medical Education (RMCH)
• Divisional Director Surgery and Theatres (RMCH)
• Associate Chief Medical Officer, Workforce and Medical Education
• Trust Director of Medical Education
• Associate Director of Medical Education
• Head of Service Postgraduate Medical Education
• Operational Service Manager
• Medical Director (Wythenshawe)
• Director of Medical Education (Wythenshawe)

Review panel

• Professor Paul Baker, Deputy Postgraduate Dean, Quality Review Lead
• Mr David Ross, Associate Postgraduate Dean, link Associate Dean (Hospital) for the trust
• Miss Charlotte Defty, Regional Training Programme Director, Mersey
• Rowena Jackson, Lay Representative
• Fiona Lowndes, Quality Support Manager
• Leanne Moore, Quality Coordinator
• Kieran Armstrong, Quality Administrator

Review findings

Session 1: Resident doctors in plastic surgery

• Domain 1 Learning Environment and Culture  
• Domain 3 Developing and Supporting Learners
• Domain 5 Delivering Curricula and Assessments

Induction

All but one of the resident doctors had attended an induction and knew how to find information on a share point induction site.  We had been advised by the trust that induction had been changed to a day at each of the 3 sites to be covered. Resident doctors commented that for doctors new to the NHS, then a more comprehensive induction was required.  Although there was meant to be a shadowing period to meet this need, it did not always happen due to service demands. The comment was made that although it was useful to have an induction to all 3 sites, this meant that there could be a long gap between the induction for a particular site and starting a rotation there.

Training experience  

Resident doctors reported that the emergency/trauma element of the jobs was stressful, primarily due to the model of care at RMCH. Paediatric minor injuries and trauma cases had to be dealt with on an ad hoc basis and the residents were responsible for the administration of the patient pathway. Consequently, they spend considerable amounts of time apologising to families and patients due to waiting times and cancellations, as there was no dedicated trauma list.  This was impacting on their ability to access other training opportunities.  However, it was reported that the trust had recently implemented a dedicated afternoon trauma clinic so paediatric trauma cases could be referred for treatment there. The SHO would assess the patient and the registrar would book them into trauma clinic.  The operational team are now providing support with the booking of patients into dedicated plastic surgery trauma lists and undertaking much of the admin required for this. There is an ANP who provides support in the Trauma Clinic. As this was recently introduced, resident doctors said it was too early to say if this would help the patient flows and ad hoc demands. Additionally, all were encouraged to use the plastics trauma list which has recently been introduced, rather than the CEPOD emergency list. The latter is still used due do timing and capacity of the trauma lists.

Resident doctors were asked if they had workplans, and said they did not but they were split between burns and cleft work. The panel noted that there was a burns list 3 times per week. Resident doctors reported that there were difficulties gaining the volumes of cleft cases required and had to be proactive to gain the necessary experience. The rotations included 3 months of cleft experience, but resident doctors said that even if they attended every cleft case, it would still be difficult to acquire the volumes required by the curriculum due to the high number of cancellations. The cleft clinic also clashed with burns clinic.  In order to gain experience in cleft cases, resident doctors said that they had to miss teaching sessions, and attend on some zero days.

Resident doctors were still able to achieve the indicative logbook requirements for cleft by logging their experience of video fluoroscopy attendance.  Whilst this is a valuable part of cleft training, there were concerns that this was accounting for an ill-proportioned number of cases on their logbook.  They were keen to attend more cleft surgery lists to change this trend. It was reported that there were 4 ‘juniors’ working in the department, and therefore a tight ‘SHO’ rota, which meant that the higher grades were ‘picking up the slack’ and doing procedures themselves, e.g. nailbed repairs, rather than there being time to teach the SHO to do this. It was explained that as the rota for juniors was 1 in 8, if there was any leave taken, this impacted on ward cover. Resident doctors said there were interesting cases, but they were restricted in how much time they had free, due to service pressures and time taken supporting the SHO tier.

Teaching and audit

It was reported that the whole plastics department arranged an audit day every 3-4 months and resident doctors could input into the agenda.

There was national teaching in plastic surgery once a month and resident doctors could attend online. They were officially given time to attend, although time was not given to watch the recording if they were unable to attend in real time for any reason.  Regional teaching was described as ad hoc, and that there was not much need for it. The core resident doctors did attend regional teaching and reliably got time to do this.  A local teaching programme was newly established, but resident doctors could not always attend.

It was noted that there was now a chief registrar and resident doctors could feed back issues to them. There was also a meeting of all resident doctors at audit day.

Supervision and support

Registrars had received feedback that SHOs did not feel supported and they thought that the registrars should be there for a face to face handover at 5 pm despite potentially working at a different site. This would then impact on their clinical commitments elsewhere due to travel time.  Their on call would still otherwise be non-resident.  It was felt that this change was another example of the registrars having to do something additional (as a virtual meeting could work for handover) that impacted their other clinical commitments due to the SHOs either not being supported adequately during the day or not being able to complete their workload.

The residents explained that the SHO tier is a combination of CTs and LEDs. The competencies and experience particularly within the latter group, often new to UK practice, were such that they required significantly more supervision. This exacerbated the previously mentioned issues with the SHO workload and responsibilities. Consequently, registrars were having to fill the gap. Registrars commented that if the SHO was not supported during the day, it should not be a handover/registrar issue, the problem should have been addressed during the daytime shift but this was often difficult to resolve, due to service demands.

Registrars said that SHOs were often new to the NHS and new to plastics and required additional support. Registrars were supportive and advocated for a shadowing period to support new SHOs, but due to providing this support, their own training was impacted.

Resident doctors said they were well supported and could access senior support when required.

Nurses in the burns team were also commended for the support they gave.

It was noted that registrars were not allocated self-development time, though core resident doctors were.

Handover

The new handover system was described as good. It was noted that the consultant on call covered burns and plastics, and the SHO after a night shift attended handover. The handover list was described as accurate and was embedded in HIVE for both plastics and burns, and patients were not missed.  It was noted that there were not many plastic surgery inpatients.

It was noted that plastic surgery residents working at other sites during the day (Wythenshawe and The Christie) were on the on call rota, and they had to be on site at RMCH for the 5 pm handover. Resident doctors said that this led to issues, as it was not always possible to leave other sites early enough and at times there was a lack of understanding from the consultants at the other sites.

Equality, Diversity and Inclusion (EDI)

All resident doctors said that working relationships were good in the trust, and that patients were treated with dignity and respect. The culture in the department was described as excellent, with a cohesive group of staff and no divide between burns and plastics. However, there had been a report of some incivility displayed by a member of anaesthetics staff in theatres. Resident doctors said that they felt anaesthetists viewed plastics as a secondary service and not a priority, and resident doctors had to fight for their patients. They described the anaesthetists as ‘gate keepers’.

The panel asked if resident doctors had discussed this issue with their supervisors, but they had not raised this formally.

Domain 2: Educational Governance and Commitment to Quality

Incident reporting

All resident doctors were aware of how to report incidents; however, it was not clear if feedback was always received directly.  There were M & M meetings held, especially for never events.

Exception reporting

The panel asked about the exception reporting process. Resident doctors said that exception reporting was not encouraged and had the perception that they would lose the respect of consultants if they reported. They also said they were reluctant to exception report for fear that their rota would be changed unfavourably as they felt this had been done in a different department within the hospital, rather than addressing the issues leading to exception reporting. However, it was noted that there was not much need for exception reporting at the RMCH site.

The panel clarified that doctors were aware of other reporting routes, e.g. via chief residents, or the guardian of safe working, or group anonymous feedback.

Recommendation of placement

The panel asked if resident doctors would recommend their post and what were the positives and negatives about it.  Two said yes they would recommend, 2 said no and the remainder did not commit.  Positives from the placement included the training experience available and good team working.  Negatives included the organisational structure, the way the service delivery model, and the consequences of having to support a short staffed SHO tier.

Domain 4: Developing and supporting supervisors

The panel explained why the visit was taking place and asked supervisors if they felt supported, and if structures worked for them.  All supervisors confirmed that they received an allowance for supervision of 0.25 per resident doctor without a cap and this was reflected in job plans.  All resident doctors had an educational supervisor and all education supervisors had been trained for the role.

All confirmed that they had opportunities for continuing professional development, with regular opportunities circulated and there was also a share point site for educators. Courses were repeated regularly to provide maximum opportunity to register for most courses, although it was noted that a one day educators course regularly filled up quickly. The department arranged separate training days for SAS/CESR doctors. The comment was made that education was ‘front and centre’ in the appraisal process.

It was reported that although the priority for the trust had been waiting times, there was more opportunity now to focus on training. There were no barriers to attending study days.

Supervisors were asked how they supported equality and diversity and they said they role modelled respectful behaviours and that with a diverse body of resident doctors and consultants they were well placed to treat a diverse community.

It was acknowledged that many locally employed doctors were facing the challenge of being new to the NHS, and/or new to the UK.  A 2-week shadowing period was usually offered at RMCH, however this had not been possible for all. They were also signposted to the GMC’s introductory course ‘welcome to UK practice’.  A senior doctor on the burns team was trained in Nigeria, and acted as a mentor to doctors new to the UK. The chief residents also provided support.

There was also a share point site run by the postgraduate medicine department for locally employed doctors (LEDs) to access. There was an e-mail distribution list for International Medical Graduates (IMGs), and courses were available and publicised to support, including how to complete portfolios. Support was provided to doctors returning to training after a break, or doctors requiring adjustments.

The panel raised the issue of workforce challenges, and it was reiterated that the goal was to move from a 1 in 8 to a 1 in 10 rota, which formed part of a business plan submission. It was acknowledged that the biggest concern was the SHO tier and the funding required to increase that level of workforce. Resident doctors were supportive and described as ‘outstanding’ but it was appreciated that supporting the SHO tier had a knock on effect on resident doctor  workloads and training opportunities. Supervisors said that recruitment had been challenging, and post BREXIT, a higher proportion of applicants were new to plastics or paediatrics, and/or new to the UK. This had an impact, including the need to provide an induction which is a more ‘comprehensive education’. The way in which recruitment had to be transacted via the TRAC system was very time consuming, and there had been occasions where experienced candidates had missed out, due to the way the recruitment process was conducted (applications closing based on numbers of applications received as opposed to being time based). The department had requested a closed round of recruitment prior to the role being advertised openly, but HR had said this was not possible.

This had a knock on effect on the service including more frequent staffing changes, more support required from seniors, and sickness related absence. Supervisors said that last minute changes to the rota were minimised, but occasionally there was on the day sickness.

Regarding the training opportunities, it was noted that 3 months cleft and 3 months burns experience was scheduled in. It was also confirmed that a trauma list had recently been introduced, and there was now a trauma coordinator, relieving the pressure on SHOs. There was always a burns consultant of the day available and a consultant at the morning handover. Paediatric plastic surgery was covered from Monday to Friday, and there was always a consultant present. Supervisors said they would remind resident doctors to let them know that consultants were there to support SHOs and resolve any issues. They expressed concern that resident doctors were taking on too much responsibility for resolving issues.

The panel fed back to the supervisors, that attending the 5 pm handover had been difficult for resident doctors at other sites, however it was noted that the suggestion had been made by some resident doctors.  It was thought that the need for a 5 pm face to face handover was due to SHOs requiring support. It was noted that there used to be an afternoon ward round but this was no longer the case.

The panel fed back that resident doctors were reluctant to exception report, and supervisors confirmed that it was encouraged, but understood that resident doctors were fearful that a full shift rota would be implemented.

The panel raised the issue of feedback from resident doctors and suggested that exit interviews would be useful, and consideration of anonymous methods of getting feedback.

Areas that are working well

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Fiona Lowndes, Quality Support Manager
Review lead: Professor Paul Baker, Associate Postgraduate Dean
Date approved by review lead: 3 June 2025

NHS England authorised signature: Dr Raghu Paranthaman, Deputy Postgraduate Dean, Hospital and Community Medicine, NHS England North West Workforce, Training & Education Directorate
Date authorised: 4 July 2025

Final report submitted to organisation: 12 August 2025