Executive summary

The primary purpose of the Monitoring the Learning Environment (MLE) meeting is to review learner experience data as last year General Surgery and Core Surgical Training (CST) performed poorly compared to regional and national peer trusts.

• A learner visit took place in February 2024 and an educator visit took place in September 2024.
• A specialty concern for Surgery was opened following the learner visit in February due to poor General Medical Council National Training Survey (GMC NTS) feedback for CST, Speciality Training and Foundation, with persistently poor feedback in a number or areas, including all surgical specialty training, workload versus training opportunities and handover.
• The trust was commended for their hard work in Surgery. No requirement in Surgery will be set and the issue will remain a specialty concern within the School of Surgery and will continue to be monitored by NHS England.
• Since the interventions there has been a repeat of the GMC NTS data, and the overall feedback is that significant improvements have been seen in learner experience in CST. There are still some concerns in General Surgery, but measures have been put in place in the trust.
• Concerns in Emergency Medicine, Gastroenterology, Surgery, and Cardiology may need a requirement or speciality concern opened due to regulator interest.
• The trust will report on progress in six months’ time including providing evidence of Postgraduate Doctors in Training (PDiT) engagement and an action plan for the open specialty concern.
• A MLE will take place in six months’ time and a Senior Leader Engagement (SLE) visit will take place in January 2026.
• NHS England will review the trust’s response to concerns in Emergency Medicine and Medicine within the next three months with the aim of implementing a quality improvement plan.

Review overview

Background to the review

Monitoring the Learning Environment 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. The visit was triggered in response to the GMC NTS data.

Evidence

• GMC NTS results and priority list
• GMC Patient Safety comments for local monitoring
• National Education and Training Survey (NETS) results
• Surgery Learner/Educator feedback – February and September 2024
• Trust all open requirements report

Who we met with

• Director of Medical Education
• Deputy Director of Medical Education
• Associate Director – Medical Directorate
• Medical Education Manager

Review panel

• Chair, Adam Burns, Quality Associate Dean
• Specialty Expert, Emma Collins, Training Programme Director, Core Surgical Training
• Quality Lead, Joanne Seddon, Quality Support Manager
• Admin, Michele Hannon, Quality Administrator     

Review findings

Education quality domain 1: Learning environment and culture

GMC NTS

The trust shared a presentation outlining detailed action plans for surgical specialties in response to the GMC NTS and provided the following update:

• The trust stated that Plastics, Urology, General Surgery, and Trauma and Orthopaedics (T&O) have a robust plan to improve quality. More work is planned, and this should result in improved learner experience for next year.
• There is a co-ordinated multi-level trust response to training issues including corporate, medical educational and divisional responses. Efforts have been made to increase doctor numbers to improve workload and rota design.
• The Medical Education team are awaiting sign off for a business case for a specialty lead in each specialty who is responsible and accountable.
• PDiT will be involved in the quality improvement process through the resident doctor forum.
• NHS England queried if anything further had been discussed at the trust regarding incivility comments from the GMC NTS.
• The trust recognised the need to action concerns promptly and advised this had been flagged with the Chief Medical Officer (CMO) prior to the meeting. Any anecdotes go straight to the Head of Clinical Services even if they are not named and these are escalated quickly, and a response is requested.

Actions agreed

• The open specialty concern for Core Surgical Training, Speciality Training and Foundation will remain open and continue to be monitored by NHS England and the School of Surgery.
• NHS England to arrange a further MLE in six months’ time and the trust to provide an update and feedback from the current PDiT, and a report on the items listed in the presentation.
• The trust agreed to look at the presentation with the senior Medical Education team with the possibility of scheduling a survey monkey approach potentially in 6 weeks and then in 5 months’ time to see if there is a trend.

GMC NTS priority list

• NHS England outlined there are 3 areas that are flagged; Emergency Medicine, Gastroenterology and Stroke Medicine which have all had a significant degradation in performance.
• Gastroenterology was previously in enhanced monitoring and Endoscopy accreditation was withdrawn.
• The trust queried how far back the data went for Gastroenterology as there were less than 3 responders for 2024.
• NHS England advised that they may be sorted by higher specialty and site which increases numbers, but we need to understand the data when the final list is received.
• The trust queried if the triple red for Gastroenterology handover and workload by speciality was specialty or the general medical rota.
• The trust felt that feedback captured wider issues across acute and general Medicine as there is no specialty specific handover process out of hours. The trust will look at producing a combined approach within acute and general Medicine. General divisional Medicine is being captured and it is the handover in the evening to a general medical person which is falling, and they need to look at this but also a more overall coordinated approach to look at general Medicine out of hours.
• NHS England advised that the GMC have access to all data including N<3 but there are lots of reds in Medicine and suspected that this could be divisional Medicine, and work will be required by the trust to identify this.
• Cardiology does not appear on the priority list, yet the data is particularly weak and is a significant poor outlier regionally.
• The trust was also surprised about Cardiology as although it was not a triple red the recent red is causing concern.
• The trust stated that in Cardiology, higher speciality PDiT often want to focus on Cardiology, but there will be a significant general Medicine component, and expectations need to be managed.
• NHS England reported that the School of Medicine are planning a review of Cardiology training.
• The trust is hopeful that improvements will be seen as there has been a restructure and there have been 100 Locally Employed Doctors (LED) this year to help Medicine and additional Foundation PDiT so the numbers are much better which should reflect in improvements in the next survey.
• There is ongoing work to rota in training time alongside clinical commitments. Internal Medicine Training (IMT) have rostered days to attend clinics, and it has been calculated so they get time for their Annual Review of Competency Progression (ARCP). However, there is further work to do in specialty training to achieve a similar level.

GMC NTS patient safety comments for local monitoring

• NHS England advised that trust responses to patient safety comments are shared with the GMC who advise where local monitoring is required. However, some comments require extra assurances.
• Extra assurance is needed around locum staff not having access to IT services. The trust advised that they are as assured as they can be that the process is very clear and advise that almost all locum provision tends to be long term and therefore will have access to services and IT system, but the trust cannot guarantee that locums will recognise they have access and use them.
• NHS England queried if the trust has picked this up with Corporate Governance?
• The trust advised that this has been the subject of at least one internal audit in 10 years, but the key is looking to make locum usage almost zero and the trust have had a 2500-hour reduction in locum use.
• NHS England added that if this has been audited previously and the use of locums has reduced, we are as assured as we can be.
• The trust has expanded out of hours cover to limit the risks if a locum doctor needs time or training to access a clinical system.
• NHS England stated that the patient safety concern around Cardiology access to care and clinical judgment not being acted on has been dealt with by the trust. The trust advised that they had not chased any additional responses.
• NHS England received assurances that there were robust processes in place to identify patients in need of cardiac monitoring and ensure they were placed in an appropriate clinical area.
• NHS England queried how out of hours at Dewsbury and concerns about safety, was being dealt with.
• The trust advised that the number of doctors per shift has increased from 2 to 3 on a night which has increased the feeling of safety.
• The trust was not aware of a higher number of incidents and suggested that this could be perception about supervision. Trust monitoring data did not suggest any increased patient safety risks at Dewsbury Hospital. The trust had well established protocols to escalate the care of the unwell patient at Dewsbury Hospital.
• Posters have been used previously and they are trying to put these in place to raise awareness of protocols amongst resident medical staff.
• NHS England queried if there was a tier three Registrar at Dewsbury.
• The trust advised that there was Registrar cover until 8pm and advised that there was an Anaesthetics practitioner at Registrar level that works 24/7.
• There has previously been a Registrar at Dewsbury but there was not enough for them to do so they were encouraged by the deanery to not have this as it was felt cover should be where needed.
• NHS England added that this will need to be monitored but recognised that there must be enough work for supervision to take place and recognise the need to get the balance right.

Agreed further actions

• Trusts had been asked to provide an action plan regarding any areas of concern by the end of October 2024. This will include an action plan regarding issues in Medicine and Emergency Medicine.
• NHS England will review the action plan once provided and decide if any further interventions are required.
• The trust was aware that the concerns in Medicine were significant enough to have been raised by the GMC.
• Subsequently, NHS England and the trust were aware of the need for a robust action plan with the ability to produce improvements within a defined timeframe. Such a plan would be produced jointly and would be informed by both the NTS scores, GMC comments and the provided trust action plan.

Areas that are working well

Report approval

Report completed by: Joanne Seddon, Quality Support Manager
Review lead: Adam Burns, Associate Dean for Quality
Date approved by review lead: 22 October 2024

NHS England authorised signature: Jon Hossain
Date authorised: 7 November 2024

Final report submitted to organisation: 10 December 2024