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Executive summary
Overall, feedback has significantly improved since our last visit regarding training opportunities, ward rounds and raising concerns. There have been notable improvements to training and education in T&O, particularly for core and foundation resident doctors. There was good representation from foundation, core and higher resident doctors in training.
Positive feedback was shared in relation to the following areas:
All foundation, core, and higher resident doctors were complimentary about the consultants, educators and the overall culture within the T&O department. Foundation and core resident doctors all reported that they would recommend the post to their peers.
Foundation resident doctors reported that although this placement can be daunting as a first job, they feel well supported and it is a good learning experience. Foundation resident doctors all reported that they are clearly advised at induction that they should not be managing ward rounds on their own and this should be done with a core resident doctor. This was raised as a concern at the previous visit.
It was reported that due to structural changes that the department has made to the rota, resident doctors feel that weekend working is no longer unmanageable. Core resident doctors reported that they now have their own rota, and the trust has recruited an extra registrar for weekend working. Weekend working was now being described as sufficiently staffed.
Core resident doctors are now complimentary about the training opportunities due to the changes made to the rota. They reported that they have more access to theatres and clinics and training is prioritised. It was reported that overall, everyone in the department is pro teaching.
There were no further issues reported around raising concerns. Core, foundation and higher resident doctors reported that they know how and who to report concerns to and added that they have not needed to so far.
Higher resident doctors are less content and reported that due to current vacancies at their level they are being pulled from their substantive consultant lists to cover rota gaps in other areas at short notice. It was acknowledged during the educator session that the rota coordinator has recently left post and a new member of staff is due to start imminently which they hope will address the current issues that they are experiencing.
It was apparent that there appears to be some misunderstanding of the roles and responsibilities of a resident doctor when they are in theatre with surgical care practitioners. They felt that this has led to missed training opportunities.
Based on the review findings we will be recommending that the Intensive Support Framework (ISF) category 3 is lowered to an ISF category 2. We will be requesting an update from Training Programme Directors in January 2025 and survey results will continue to be monitored to ensure the improvements made in T&O are sustained.
Review overview
Background to the review
Following several quality visits and due to outstanding areas that needed addressing in T&O for core and foundation resident doctors, T&O remained on the quality improvement register as an intensive support framework category 3.
To summarise, the main concerns highlighted at the previous visit in November 2023 that still needed addressing were:
- Training opportunities – Core resident doctors in T&O reported that they were not receiving the appropriate curriculum opportunities.
- Ward rounds in T&O – Foundation resident doctors reported that they do ward rounds on their own. Foundation resident doctors are teamed up with a core resident doctor on the ward round, but the foundation resident doctors perceive this as being on their own because they split the ward round into two. Foundation resident doctors cover one half and core resident doctors manage the Core resident doctors in T&O described the ward rounds at weekends as an unmanageable workload. These are covered by either one core resident doctor or an F2.
- Raising concerns – resident doctors reported that they can raise concerns but very rarely receive a response back which deters them from raising anything. It was perceived there is a culture of being told to improve time management if they exception report.
A follow up visit was organised for October 2024 to review progress for the mandatory requirements on the improvement plan.
Who we met with
Learner
- Foundation, Core and Higher resident doctors in T&O Educators
- Clinical and Educational Supervisors Education Team
- Education lead
- Previous Deputy Director of Medical Education
- Medical Education Manager
- T&O Manager
Review panel
All panel members listed below are colleagues from the Workforce, Training & Education directorate at NHS England.
Education Quality Review Lead
- Rob Powell – Deputy Postgraduate Dean Specialty expert
- Rob Williams – Training Programme Director for Professional Affairs for Surgery
- Rachel Parry – Head of School, Foundation LLR NHS England Education Quality Representatives
- Kerry Olley, Quality Deputy Manager
- Cassie Morgan, Quality Manager
Review findings
Out of Hours Support/ward rounds
At previous visits, foundation resident doctors raised concerns regarding managing ward rounds on their own. The department provided assurances at this visit, during the educator session, that foundation resident doctors are advised at induction that the ward rounds should be carried out with a core resident doctor. Foundation resident doctors confirmed they are advised of this at induction. It was reported that some ward rounds are being carried out solo however this is down to choice. Foundation resident doctors reported that ward rounds work well, and they are well supported by senior colleagues.
Core resident doctors in T&O no longer reported that the ward rounds at weekends are unmanageable. There are now two higher resident doctors on the rota at weekends, so even though weekends are still being reported as busy they are manageable. They were reported as being sufficiently staffed and no patient safety concerns were highlighted.
It was reported by foundation resident doctors that inappropriate patient referrals to T&O from the accident and emergency department can at times make them feel pressured if they do not have a higher resident doctor with them if they need to challenge it. It was reported that the trust continues to work on managing this.
Training opportunities
It was reported that core resident doctors now have their own rota, and they are no longer on the same rota as foundation resident doctors. They confirmed that because of this change, training opportunities have significantly improved, and they now have dedicated theatre time and on average spend two to three days per week in theatre. When in theatre core resident doctors reported that they get to know the consultant well and consequently reported feeling much more involved. The majority of consultants were reported as being keen trainers.
It was reported by general practice (GP) resident doctors that they predominantly provide service provision, but they are currently having discussions with supervisors to see how they can get the most out of this post. It was reported that they would benefit from attending more outpatient clinics. They also reported that it would be good if the trust has a better understanding of what GP resident doctors need from these placements.
Higher resident doctors reported that there has been a period of vacancies and subsequently they are being pulled from their substantive consultants lists to cover vacancies in other areas at short notice which is having a negative impact on their training. They reported that the proportion of clinics they attend is currently higher than theatre. It was apparent that there appears to be some misunderstanding of the relevant roles and responsibilities when resident doctors are in theatre with surgical care practitioners and how training is optimised. It was felt that when this happens, the training opportunities available for higher resident doctors become limited.
Higher resident doctors are allocated to one consultant, and it was reported that the majority have a lot of theatre exposure but some reported being pulled from elective theatre to cover fracture clinics.
Raising concerns
Resident doctors raised no further concerns at this meeting. In addition, they stated that they knew how to raise concerns within the trust but had had no need to do this.
Rota
Foundation resident doctors reported that they are having to work an extra hour every day after their shift to ensure a smooth handover because of the current rota timings. The day shift rota is currently 12pm – 8pm but the evening rota doesn’t start until 8.30pm therefore they need to remain after their shift has ended to allow for handover. During the educator session it was however confirmed that as of December 2024 the rota is being changed to 1pm – 9pm so this issue will be resolved.
Higher resident doctors reported that they now have one higher resident doctor in theatre and one on call which was described as ‘good’.
It was however reported by higher resident doctors that since the rota coordinator has left post the gaps are not being managed as well as they have been previously. They reported they are being asked to cover gaps at short notice (on the same day) which they hope is resolved when the new member of staff starts in post on 4 November 2024.
It was reported however that no study leave or annual leave requests have ever been refused.
Areas that are working well
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
| Training Opportunities It was reported that core resident doctors now have their own rota, and they are no longer on the same rota as foundation resident doctors. They confirmed that because of this change, training opportunities have significantly improved, and they now have dedicated theatre time and on average spend two to three days per week in theatre. When in theatre core resident doctors reported that they get to know the consultant well and consequently reported feeling much more involved. | 3.6 |
| Ward rounds Foundation resident doctors reported that ward rounds work well, and they are well supported by senior colleagues. Core resident doctors in T&O reported that the ward rounds at weekends are no longer unmanageable. There are now 2 higher resident doctors on the rota working at weekends, they are reported as still being busy but manageable now they are sufficiently staffed, and no patient safety concerns were highlighted. | 1.5 |
| Raising concerns All resident doctors were happy with the ability to raise concerns. They all reported that they have had no need to raise any concerns, but that they know who to report to if they did. | 1.7 |
Areas for improvement
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| MR 1 – Training Opportunities (Higher resident doctors) Higher resident doctors reported that there has been a period of vacancies and subsequently they are being pulled from their substantive consultants lists to cover vacancies in other areas at short notice which is having a negative impact on their training. | Trust to review rota gaps to minimise the frequency of higher resident doctors being pulled to cover rota gaps at short notice which is having a negative impact on their training. | 3.7 |
Recommendation
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
| General practice (GP) resident doctors reported that they predominantly provide service provision, but they are currently having discussions with supervisors to see how they can get the most out of this post. It was reported that they would benefit from attending more outpatient clinics. They also reported that it would be good if the trust has a better understanding of what GP resident doctors need from these placements. We would recommend that the trust reviews the learning opportunities for GP resident doctors to maximise their learning potential during this rotation. | 3.6 |
| Higher resident doctors It was apparent that there appears to be some misunderstanding of the roles and responsibilities of a resident doctor when they are in theatre with surgical care practitioners. They added that this has led to missed training opportunities. It was suggested to the trust during the educator and feedback session that it would be beneficial to organise a meeting so they are all together and can get a better understanding of their relative roles and discuss expectations. |
Report approval
Report completed by: Kerry Olley, Quality Deputy Manager Review lead: Rob Powell, Deputy Postgraduate Dean
Date signed: 31 October 2024
NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean
Date signed: 27 November 2024
Final report submitted to organisation: 24 December 2024