Executive summary

NHS England – London’s Education Quality Team scheduled this educational quality review to North London NHS Foundation Trust due to concerns raised within the General Medical Council’s National Training Survey (GMC NTS) 2024 results across General Psychiatry, Liaison Psychiatry, Core Psychiatry Training and Foundation Psychiatry programmes at Highgate Mental Health Centre.

The review panel thanked the Trust for accommodating this quality review and for facilitating good attendance on the day. After discussions with the Trust’s educational management team, resident doctors training in the programmes and clinical and educational supervisors, the review panel identified some key areas for improvement and some areas that were working well within the Trust.

It was clear to the panel that the Trust were aware of the concerns raised by resident doctors (RDs) and that they had devised plans to improve the experience of training. This included investment in Human Resources, improvements to the academic teaching programme and quality improvement projects with input from RDs. 

Serious concerns:

The Trust was issued three Immediate Mandatory Requirements (IMRs) at the quality review, pertaining the Clinical Supervision arrangements for Foundation Psychiatry resident doctors and Core Psychiatry Training resident doctors, and patient safety concerns pertaining to physical health recording and escalation of acutely unwell patients by some of the Nursing staff. The Trust has actioned and responded to the three IMRs, and these remain open for further monitoring by NHS England’s Education Quality Team.

Areas requiring improvement:

• Organisational culture and its response to concerns raised by resident doctors, and a lack of clarity around the relationship of individual meetings to Trust governance and decision making
• Limited communication and transparency on concerns raised regarding the inappropriate behaviour of staff
• Access to teaching for Foundation Psychiatry resident doctors
• Local Induction into Highgate Mental Health Centre
• Disparity of workload between Highgate East and Highgate West sites

The panel assigned provisional Intensive Support Framework (ISF) ratings for the programmes as following:

• General Psychiatry: ISF 3
• Liaison Psychiatry: N/A (the panel did not meet with a sufficient number of liaison psychiatry resident doctors to enable an ISF rating to be attached to the programme)
• Core Psychiatry Training: ISF 3
• Foundation Psychiatry Training: ISF 3

NHS England’s Education Quality team will monitor the sustainability of these improvements via the IMRs and Mandatory Requirements on the Quality Management Portal (QMP) which can be found towards the end of this report.

Review overview

Background to the review

NHS England – London scheduled this quality intervention to Highgate Mental Health Centre at North London NHS Foundation Trust due to concerns raised in the GMC NTS 2024 results across multiple programmes at Highgate Mental Health Centre, and subsequent self-report responses. This included General Psychiatry, Core Psychiatry Training, Foundation Psychiatry and Liaison Psychiatry.

Whilst improvements had been planned and implemented by the Trust, the sustainability of these improvements was still of concern, therefore NHS England conducted this learner and educator review to explore the issues further and support the Trust to ensure the sustainability of these improvements.

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

• Garnet ward – Unexpected Death
• Camden and Islington Local Trainee Survey Liaison Psychiatry Posts – October 2024
• Core Psychiatry Training consultation 4th September 2024
• Core Psychiatry Training – resident doctor feedback
• December Annual Review of Competency Progression (ARCP) Quality Improvement Project (QIP) Report
• Document for the Education Quality intervention
• Draft minutes re discussion of General Medical Council (GMC) feedback December 2024
• Exception Report log for Educational review – redacted version
• Feedback – Camden and Islington resident doctors’ induction – Wed 7th & 8th August 2024
• GMC Survey presentation to resident doctors 6.11.24
• Highgate resident doctor Incidents 2024 (updated)
• Highgate Mental Health Centre East and West Resident Doctors and Clinical Supervisors December 2024
• Induction Quality Improvement project – focus group feedback – November 2024
• Minutes for Highgate Junior – Seniors Meeting 06.11.24
• Minutes of Partnership Medical Education Committee – October 2024
• North Central London Higher General Adult and Old Age Resident Doctor Survey December 2024
• North London Foundation Trust – Trust-wide rota gaps
• North London Foundation Trust Hospital Division Report
• Results of North Central London Core Training Survey December 2024
• South Side feedback – December 2024
• Understanding and Improving the Foundation training residency experience 28.11.24
• Understanding and Improving the specialty training residency experience 6.11.24

Who we met with

Learners

• Six Foundation resident doctors working in a psychiatry placement, foundation years 1 – 2 (F1-2)
• Ten Core Psychiatry Training (CPT) resident doctors, core training years 1 – 3 (CT1-3)
• Nine higher specialty resident doctors training in general psychiatry and liaison psychiatry, specialty training years 4 – 7 (ST4-7)

Educators

• Eleven clinical and educational supervisors for the general psychiatry, liaison psychiatry, CPT and foundation programmes

Education team

• Two Co-Directors of Medical Education
• Head of Medical Education
• Postgraduate Manager
• Medical Director
• Site Tutor
• Two Training Programme Directors for North Central London Core Psychiatry
• Training Programme Director for General Adult Psychiatry and Old Age Psychiatry, Nort Central London
• Two Training Programme Directors for Foundation (Whittington and Royal Free Scheme)
• Freedom to Speak Up Guardian
• Guardian of Safe Working Hours

Review panel

• Dr Vivienne Curtis, System Dean – North Central London, Education Quality Review Lead. NHS England – London
• Dr Luca Polledri, Head of the London School of Psychiatry, Specialty Expert. NHS England – London
• Dr Nicole Eady, Deputy Head of the London School of Psychiatry, Specialty Expert. NHS England – London
• Dr Celia Bielawski, Deputy Director of the London Foundation School, Specialty Expert. NHS England – London
• Dr Josephine Agyeman, Fellow in Medical Education (Psychiatry), Learner Representative. North East London NHS Foundation Trust
• Jane Gregory, Lay Representative. NHS England – London
• Nicole Lallaway, Education Quality Coordinator. NHS England – London

Review findings

Trust presentation

The Trust delivered a comprehensive presentation to the NHS England review panel, detailing an overview of the Trust, educational quality concerns and actions undertaken to make improvements. It was acknowledged that two Trusts merged in November 2024 to form the new North London Foundation Trust, previous Trusts being Barnet, Enfield and Haringey Mental Health NHS Trust and Camden and Islington NHS Foundation Trust. As a result, the new Trust provided care to patients within 5 boroughs within North London. The Trust reported that there was an increase in quality concerns identified in the General Medical Council’s National Training Survey (GMC NTS) 2024, with red outliers flagged in Liaison Psychiatry in Camden and Islington NHS Foundation Trust, General Psychiatry and Core Psychiatry Training (CPT) at Highgate Mental Health Centre (HMHC), and a deterioration in results within Foundation Psychiatry Training Year 1 at HMHC.

The Trust spoke of their improvement strategy, which included developing leadership within Medical Education, engaging consultants and clinical leadership, investments in the postgraduate team and establishing Local Faculty Group (LFG) meetings for core, higher and foundation training. The panel also heard that work was undertaken to engage resident doctors (RDs) in improvement initiatives, such as establishing monthly junior / senior meetings, consulting with RDs on the GMC NTS results and involving RDs in Quality Improvement Projects (QIPs) around induction, clinical supervision, handover and improving the specialty training experience.

The Trust mentioned specifically about a QIP to improve handover, which was at present a work in progress, but the Trust was looking at introducing when handover took place, introducing protected time for handover and provision of a physical space to have a face-to-face handover meeting.

The Trust reported that it intended to improve teaching for RDs by developing a full day of core psychiatry teaching on Wednesdays, developing simulation-based learning and providing clinical supervisor (CS) and educational supervisor (ES) training for higher specialty RDs.

The panel also heard that work was being undertaken to strengthen Human Resources (HR) and rota coordination by appointing rota coordinators and facilitating an improved HR / RD relationship by engaging RDs in the development of the rota.

Quality improvement projects

Higher specialty RDs in general psychiatry reported that they were able to engage in quality improvement projects when the placement they’re working in was well staffed. However, in some placements where consultant cover was less stable, RDs were unable to contribute to any QIP going on within the Trust.

Human resources

It was clear to the panel that the Trust acknowledged that the HR service had been inadequate, and it had demonstrated a clear commitment to improve HR and its processes. Higher specialty RDs training in General Psychiatry reported having issues with HR services regarding getting paid the correct amount for their hours worked, as well as issues with the rota. The panel heard that RDs were provided with the work schedule in order to build the rota themselves. However, this was often initially accepted and then later changed by HR. When meeting with Trust management, the review panel heard that they were aware of these issues and were in the process of recruiting a separate team of five rota coordinators to be responsible for managing the rotas. The panel heard that these vacancies had gone through approval and that the posts will be advertised within the coming months. It was also highlighted that there had been an increase of less than full time (LTFT) working among RDs, with an increase from 10% to 41% of the cohort working LTFT. The Trust felt they were managing arrangements around this including provision of job shared, adequate experience and supervision arrangements. CS’ and ES’ also felt that in recent months there had been a better experience of Medical HR which appeared to be more responsive to filling rota gaps when a member of staff was on sick leave.

Clinical supervision

The review panel was seriously concerned to hear of a lack of immediate named senior support and consultant supervision for Foundation RDs working during the day on Highgate West. It was reported that Foundation RDs were often the only doctors working in some wards on Highgate West, and that their named CS’ were often consultants from another service. The review panel was also concerned to hear of a lack of immediate named consultant supervision for CPT RDs. It was reported that in split posts, the formal clinical supervision was provided by a community consultant, which left the RDs unsure of who to contact for day-to-day consultant advice and joint review.

The panel acknowledged that there was a high turnover of consultants within HMHC, with some RDs reporting that they were placed in posts where their named consultant was about to leave or had just left the job. Some RDs reported that they had more than four consultants within a six-month period. The Trust often tried to find a CS to provide support for RDs, however they were often community-based consultants with limited contact time with RDs. This was echoed by the consultant cohort who were acutely aware of the limited pool of consultants available to provide clinical supervision to RDs working on wards due to substantive gaps on the consultant rota. CS’ and ES’ queried whether fixed-term consultants working in HMHC could clinically supervise RDs to mitigate some of these issues, and the review panel advised to look into the Royal College of Psychiatry (RCoP) guidance in conjunction with considerations for the level of RD.

CPT and Foundation RDs were rostered to attend a half-day clinic once per week with their named consultant, and this was their opportunity to receive direct supervision as have workplace-based assessments signed off. Higher specialty RDs in general psychiatry had less concerns about clinical supervision arrangements due to their experience working within psychiatry. This meant that the more experienced RDs knew which cases required consultant input, however it was reported that newer psychiatry RDs at specialty training grade year 4 (ST4) would be less familiar with the specialty and supervision arrangements were felt to be less appropriate for RDs at this this training grade.

Culture/governance

The review panel had concerns about the organisational culture and its response to concerns raised by RDs. There was the sense that the Trust was aware of the issues and had various meetings to discuss the problems, however, there did not appear to be clear accountability for the final decision making, nor was there a clear timeline to resolve issues. RDs reported that minutes were often not sent out in a timely manner, actions were not assigned clear timelines and action owners were not always assigned, which meant that it was difficult to identify resolutions to issues raised during meetings. The panel heard from all groups at the review that there was a large number of postgraduate education meetings, but there was a lack of clarity regarding the relationship of individual meetings to Trust governance structures and decision making.

The panel heard that Foundation RDs rotated to HMHC for a four-month placement, and the review panel queried the department’s relationships with the RDs host Trusts. Trust management reported that often their only communication with the host Trust faculty teams was when there was a problem, and it was acknowledged that this could be a more proactive relationship with regular meetings.

The review panel queried any potential impact of the merger between Barnet, Enfield and Haringey Mental Health NHS Trust and Camden and Islington NHS Foundation Trust. It was fed-back by Trust management that the core and higher specialty general psychiatry RDs always worked across both Trusts, which meant that rotations had not changed since the merger. It was felt that there may be an improvement to induction once Information Technology (IT) systems complete their harmonisation process across the new Trust, as there would be just one induction to attend, and that provision of laptops for RDs meant they would have one laptop for 3 years which would streamline the process. It was acknowledged that since the two Trusts merged, the Health Based place of Safety was now responsible for five boroughs within London as opposed to two boroughs previously, which could impact on workload.

Access to teaching

The review panel heard that Foundation RDs were unable to attend Psychiatric Academic teaching on Wednesday afternoons due to rota timetabling and ward cover. RDs reported that Foundation RDs were rostered to cover the wards on Wednesday afternoons, which meant that they were unable to attend any of the scheduled Psychiatry teaching sessions aimed at CPT RDs. However, Foundation RDs reported that they were able to attend Foundation teaching on Thursdays as required for their training programme.

The Trust informed the panel that they were currently consulting on plans to review the CPT RD Academic Programme and University College London (UCL) Member of the Royal College of Psychiatry (MRCPsych) Preparation courses to take place on Wednesday as a full day of teaching, of which the panel felt would be of benefit to RDs. However, some consideration would be required as to who would cover the wards during that day to enable all RDs to attend the teaching session.

Higher specialty RDs training in general psychiatry were able to attend their teaching sessions with no issues. It was also good to hear of plans to improve access to Psychotherapy for CPT RDs.

CS’ and ES’ reported that they were able to access regular courses to develop themselves as educators, and that they were also able to explore courses delivered by external providers as well. This enabled them to ensure they were meeting their portfolio requirements as recognised CS’ and ES’. 

Raising concerns

There were ongoing concerns about the Trust’s perceived approach to managing inappropriate behaviours of staff, particularly in relation to Equality, Diversity and Inclusion. There was felt to be a lack of clear communication and transparency around these concerns amongst the RD cohort, which was also reflected amongst the CS’ and ES’. It was also felt there was a limited offer of appropriate support to RDs who had raised concerns, and to ensure they felt empowered to continue to raise concerns about either their own experiences or perceived risks to patients. Higher specialty RDs reported that they were aware of the process for raising concerns, however they lacked confidence in having issues addressed, with some instances reported of RDs having concerns pushed back on themselves by some supervisors.

The review panel heard from RDs, CS’ and ES’ of concerns raised regarding bullying and sexual harassment. It was noted that while the Trust had followed the correct processes of investigation there was ongoing concern around rumours and inaccurate information which had lead to anxieties for staff at all levels. CS and ES’ described that they had found it difficult to support RDs during this process.

The review panel heard that CS’ and ES’ felt able to raise their own concerns.  However they  felt that there was sometimes difficulty in identifying and implementing solutions.

The higher specialty RDs described perceived difficulties and frustrations in having issues addressed by the Trust.  

The panel heard that communication and feedback from post-incident after action reviews was not clear to RDs. It was reported that RDs did not feel supported through the process and encouraged to learn and reflect.

Higher specialty RDs reported that they did not feel confident in the whistleblowing process and that some were worried about how it would impact on their reputation within the Trust. The review panel felt there needed to be a clearer promotion of the role of whistleblowing and the Trust’s procedures around this, including consideration as to how the role and process around the Freedom to Speak Up Guardian is actively promoted to RDs. 

Exception reporting

Some CPT and Foundation RDs reported that they were discouraged from exception reporting by a small number of consultants, and there were some anxieties about having to discuss any submission of an exception report with their supervisor after being told not to.

Trust management acknowledged that the number of exception reports submitted at HMHC was limited. It was reported that during induction, RDs were taught how to log in to the exception reporting system and that they were trying to promote a positive exception reporting culture. However, the Trust were aware of some reluctance among the consultant cohort around this process, and that they were reminded of the importance of the process.

Induction

The review panel heard that induction for across all cohorts of RDs did not adequately prepare them for their training placement at HMHC. Some RDs reported that they did not receive their required logins on the first day of their placement, did not receive their laptop and were not given a tour of the hospital. The panel heard that when HMHC was at a different location, RDs used to receive a walk around the hospital but since moving to the new single location on Dartmouth Park Hill, there was no tour provided. Foundation RDs in particular reported that they had to travel to various other hospitals to receive their laptops and access cards for HMHC. It was fed-back that for some of the higher specialty RDs in general psychiatry, despite being scheduled on a long-term placement at HMHC, their logins stop working at points in the year where other RDs typically rotate to other placements.

Rota and workload

The review panel heard that there was a disparity of workload between Highgate East and Highgate West sites, which meant that CPT and Foundation RDs working on Highgate West were disproportionately busy compared to CPT and Foundation RDs working on Highgate East. It was reported that both sites had inpatient wards, but Highgate West had 7 acute wards and two Psychiatric Intensive Care Units (PICU), whilst Highgate East had three rehabilitation wards and two old age psychiatry wards. The panel heard that the workload during the night was manageable, especially with two RDs on the rota, however when working during the day or on the weekend, the workload was difficult to manage for a single RD. RDs reported that concerns about the inequity between the rotas was escalated and that an audit project was undertaken to make improvements, but RDs were not aware of any actions taken by the Trust to address this.

Personal safety

CPT and Foundation RDs reported that they all had access to a personal alarm, however it was reported that even when using the alarm, a response was not always guaranteed with some instances of RDs having to run out to the nursing team for support.

CS’ and ES’ reported that personal safety was a regular topic for discussion within HMHC, including during regular meetings, academic teaching, inductions and safety huddles on the wards every morning. The panel heard that if a RD has had an incident, they can speak to their CS for support and signposting, and the Psychology team also offer a 1:1 debrief session.

Patient safety 

The review panel had patient safety concerns regarding the physical health recording and escalation of acutely unwell patients by some of the Nursing staff working in HMHC. RDs reported poor recording of physical observations due to faulty equipment (e.g. thermometer), and a failure to triage and escalate raised National Early Warning Scores (NEWS) in a timely manner. In addition, there were some reports of inadequate support provided to RDs by some of the Nursing staff during resuscitation attempts, despite being signed off on the Immediate Life Support (ILS) course.

Rest facilities

Trust management reported that improvements were being made to rest facilities for RDs to demonstrate the sense that the RDs are valued members of the Trust. This included a new rest space within Highgate East, and that the department had received funding to buy a new coffee machine.

When queried on if they felt valued by the Trust, there was a consensus among higher specialty RDs that they did not feel valued by the wider Trust, but they did feel valued as doctors by individuals working within the Trust. 

Areas that are working well

Areas for improvement

Immediate mandatory requirements

1. As requested, the Trust has conducted an audit of medical equipment on inpatient units and in emergency bags to ensure they are in good working condition.

a. Camden and Islington Emergency Bags Compliance Audit Report – 29 January 2025. The hospital division (C&I) commissions an external provider to provide and audit emergency bags on inpatient units (www.mykitcheck.co.uk). An audit was carried out on 29th January in response to NHSE’s IMR and found that 1 bag in the division was non-compliant on (redacted). The Associate Director of Nursing for Physical health has requested that the ward team address this and ensure the missing item is replaced.

b. Camden and Islington – Medical Devices Compliance Report – 30 January 2025 Hospitals Division Compliance issues recently reported in relation to medical devices have been for 4 faulty ECG machines (redacted). Engineers have attended for each ward and parts have been ordered for 3, a replacement has been ordered for (redacted).

c. Reporting system for problems with medical devices. The escalation process for Medical Devices issues is via (redacted). The Associate Director of Nursing for Physical Health leads on medical devices and is also a point of contact for ward managers for these issues.

2. The Camden and Islington Physical Health Policy is currently under review and contains the policy information on handover and escalation of NEWS2 scores in section 6.7.12-13. The Trust’s Director of Nursing has re-circulated the policy to all staff working at Highgate Mental Health Centre.

Mandatory requirements

Report approval

Report completed by: Nicole Lallaway, Education Quality Coordinator
Review lead: Prof Vivienne Curtis, System Dean – North Central London, NHS England
Date approved by review lead: 7 March 2025

NHS England authorised signature: Dr Elizabeth Carty, Interim Local Postgraduate Dean
Date authorised: 27 March 2025

Final report submitted to organisation: 1 April 2025