Executive summary

We have ongoing educational concerns which we are monitoring within obstetrics and gynaecology (O&G) and general surgery, and a learner/educator review was arranged to see resident doctors in these specialties.

The trust delivered a presentation at the start of the day and verbal feedback was provided to trust representatives at the end of the review.

Obstetrics and gynaecology

Positive findings from the review included:

• All resident doctors would recommend and there was a good range of training experiences with good supervision and feedback
• The rota for ST3 and above was working particularly well.
• Specialty induction was comprehensive and it was noted that this had increased from 2 to 3 days.
• Incident reporting was working well and learning was taking place from incidents.
• Handover in obstetrics was well organised and working well.

Areas which could be improved included:

• a more organised way of allocating opportunities was recommended for resident doctors from Foundation to ST2.
• The provision of a private space for resident doctors to use.
• Gynaecology handover. This was described as inconsistent and a senior doctor wasn’t always present, which meant there was a risk that information could be missed.
• GAU – all were unanimous in saying that the physical layout of GAU was challenging, and that the service could be improved by improving the referrals process from ED
• Trust induction. It wasn’t clear if doctors had attended a trust induction.
• Induction – should be reviewed to ensure that it is appropriate for everybody including those new to the NHS.
• As mentioned in the report there were incidents where resident doctors were being asked to consent for interventional radiology procedures which wasn’t appropriate.

General surgery

Positive findings from the review included:

• There was a good team spirit amongst resident doctors who are providing peer support.
• A broad case mix which provided a breadth of opportunities.
• The supervisors we met all seemed engaged and wanted to improve training.

Areas which could be improved included:

• The organisation of the training experience, and responsibilities for on call, e.g. ward based versus team based. There were also challenges arising from covering other services; vascular, urology and orthopaedics. Although there was a breadth of opportunities, training wasn’t organised optimally to take advantage of this.
• Resident doctors reported that they weren’t getting enough feedback and assignments still needed signing off, which is linked to the point above about the organisation of the service which was impacting on training.
• There was a perception that educational opportunities were not fairly distributed and therefore a review of the system for allocating training opportunities was required and should be made transparent.
• Resident doctors reported that local induction wasn’t comprehensive and there wasn’t a sub specialty induction, e.g. vascular, urology, orthopaedics.
• There was a lack of engagement and learning from incident reporting.
• Although the supervisors we met appeared engaged and enthusiastic, they said that they were hampered by service pressures. They also expressed an interest in attending a similar service at a different hospital, to see how things work elsewhere.

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 obstetrics and gynaecology and general surgery.  Although we have been monitoring these concerns, our last face to face learner/educator review with these specialties was in November 2019 and we wanted to review the requirements which we had previously asked the trust to meet. Since then, the concerns have been monitored via action plans and in regular meetings with patch Associate Deans, and a senior leader meeting in November 2023.

Prior to this review, both specialties were risk rated as ISF2 (significant concerns).  General Surgery had previously been in enhanced monitoring and therefore we wanted to assess concerns following the removal of general surgery from enhanced monitoring.

Who we met with

Learners

• 16 resident doctors on rotations in obstetrics and gynaecology
• 19 resident doctors on rotations in general surgery

Educators

• 8 Consultants from obstetrics and gynaecology
• 4 Consultants from general surgery

Trust presentation and feedback session

• Deputy Chief Medical Officer, NCA
• Medical Director, OCO
• Chief Officer, OCO *
• Director of Nursing, OCO
• Director of Operations, OCO
• Divisional Managing Director, Division of Surgery, OCO **
• Associate Medical Director – Education, NCA
• Postgraduate Director of Medical Education, NCA
• Postgraduate Director of Medical Education, OCO
• Head of Service, Risk & Governance, Strategy, MAR, NCA PGME
• Deputy Head of Service, NCA PGME
• Hub Lead, Education Quality, NCA PGME *
• Hub Lead, Foundation/GP/PA, NCA PGME
• PGME Administrator, NCA PGME

* Only present for the Trust presentation in the morning
** Only present for the feedback meeting in the evening

Review panel

• Professor Simon Carley, Associate Postgraduate Dean, Quality Review Lead
• Miss Fiona Clarke, Associate Postgraduate Dean, link Associate Dean (Hospital) for the trust
• Dr Nicola Hulme, Associate Postgraduate Dean, link Associate Dean (GP) for the trust
• Mr David Van Dellen, Head of School of Surgery
• Dr Liz Haslett, Head of School of O & G
• Dr Raghu Paranthaman, Deputy Postgraduate Dean, GM & Quality
• Ms Lyndsey Dodd, Education QA Programme Manager, General Medical Council (for general surgery sessions only)
• Ms Charlotte Wetton, Lay Representative
• Fiona Lowndes, Quality Support Manager
• Shelley Cunliffe, Quality Coordinator
• Carole Aitken, Quality Coordinator

Review findings

Session 1

• O&G –  foundation, GP & specialty year 1 & 2
• Domain 1 Learning Environment and Culture  
• Domain 3 Developing and Supporting Learners
• Domain 5 Delivering Curricula and Assessments

Induction

All resident doctors had attended local inductions outlining expectations and covering essential information including how to navigate I.T. systems, and were signposted to relevant guidelines on the intranet. Not all resident doctors were given time to undertake mandatory training and the majority did not recall attending a trust induction.  When asked what could have improved induction, the resident doctors said a comprehensive induction should be provided to International Medical Graduates as they were new to the NHS. The panel commented that this would also be relevant to GP resident doctors as often they were new to the hospital setting.

Training experience  

Foundation doctors were rotating between the wards and other units, and were getting a broad range of experience covering both obstetrics and gynaecology, including the gynaecology ward, labour ward and scanning clinics and said their training needs were being met. In general, GP and specialty resident doctors were getting enough relevant experience to attain their competencies but had to chase the rota coordinator to ensure they got the experience required.  The allocation of training opportunities was not as relevant as the GP and specialty resident doctors would have liked and examples were given where more relevant experiences could be provided, e.g. in colposcopy clinic, or in the gynaecology assessment unit.  The comment was made that foundation doctors and GP resident doctors had shorter rotations and it was therefore a challenge to gain the most relevant experience in the time allowed.

All resident doctors confirmed that they weren’t required to act beyond their competency levels, and would call in senior support if required.  Some resident doctors thought that taking consent in some cases would be more appropriate to be undertaken by more senior doctors, however where they did not think they knew enough to take consent, they wouldn’t be expected to do so.  The expectation to take consent was described by resident doctors as ‘tacit’. 

There was a specific issue regarding consenting for interventional radiology patients, as resident doctors in O & G had been asked to consent for interventional radiology.  Resident doctors did not feel that this was appropriate as they weren’t able to understand the procedures or the risks in depth.

Rota

The rota was coordinated by an administrative rota coordinator, but with consultant oversight.  Any specific requests were sent to the rota coordinator. From what the panel heard, the organisation of the rota and training opportunities appeared to be reactive rather than proactive.

Supervision

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

Work based assessments were signed off and there were no issues with these, apart from having to chase for sign off.

Gynaecology Assessment Unit

Resident doctors however did describe the Gynaecology Assessment Unit (GAU) as disorganised and triage was not working in an optimal way, and created service pressures.  For example, patients were being referred to GAU by A & E to be seen immediately, rather than A & E staff seeking advice as to whether a patient should be referred to GAU straightaway, or booked in for a scan.  Some of the service could be nurse led, e.g. early pregnancy referrals but workforce issues meant this wasn’t always possible.

Resident doctors also said that the GAU physical layout was not suitable with only one private room available for examinations, and this was shared with the Early Pregnancy Assessment Unit nurse.

Handover

Handovers were described as good and systematic in obstetrics and on the labour ward, but the handover on the gynaecology ward was variable as each consultant conducted handover differently, and resident doctors said there was potential for information to be missed. 

Equality, Diversity and Inclusion (EDI)

All resident doctors said that working relationships were good in the trust, that there were no EDI issues and patients were treated with dignity and respect, although resident doctors said they thought dignity was impacted by the lack of private facilities to see patients in GAU.

Domain 2 Educational Governance and Commitment to Quality

Incident reporting

The panel asked about the incident reporting process and learning and feedback from clinical incidents.  Resident doctors confirmed that there was a process to learn from incidents and there was a perinatal mortality meeting where all cases were reviewed, but unfortunately resident doctors were often too busy to attend.  All resident doctors said they were comfortable with reporting and received feedback after doing so. E-mails were sent by the trust regarding lessons learned and there were also safety huddles taking place regularly.

Recommendation of placement

The panel asked if resident doctors would recommend their post, 5 said yes, and 2 said no.

Session 2

O & G, ST3 -ST6 

We met separately with a group of ST3-ST6 resident doctors and we have detailed the findings below.

• Domain 1 Learning Environment and Culture
• Domain 3 Developing and Supporting Learners
• Domain 5: Delivering curricula and assessments

Induction

The induction for ST3+ and higher included 2 days of face to face induction in addition to 1 day for mandatory training.  This has recently been increased and will be 3 days of induction.  All were aware of how to access up to date guidelines.

Training experience  

All resident doctors said that it was a good place to train with a good mix of obstetrics and gynaecology with several sub specialty clinics.  There was a wide range of experience, and all said that they would achieve the required competencies and the rota was organised in a way that supported the acquisition of competencies.  On call was cited as a particularly good learning experience.  Those undertaking Advanced Training Skills modules had the required training opportunities allocated without having to ask for them. The rota was designed in a proactive way.

Resident doctors said that they weren’t asked to work beyond their competency levels, but did say that they had been asked to consent for interventional radiology procedures but had pushed back on these requests.  The panel agreed that they would feedback this issue to the trust.

All resident doctors said that there were lots of opportunities for audit and quality improvement initiatives but not the time to undertake as many as they would have liked.

Resident doctors said that they had been able to attend local teaching as this was part of the rota.  One of the resident doctors planned the teaching programme with a good mix of professionals inputting into the teaching.  Regional teaching was also included in the rota so that resident doctors could attend that as well as local teaching. There was also a simulation lab on site which was used occasionally for teaching.

Rota

As mentioned above, the rota provided for training requirements, including the allocation of specific requirements relating to Advanced Training Skills modules.  The rota was organised by a specialty year 3 resident doctor who had half a day to do this.  The rota coordinator supported the organisation of the rota and there was consultant oversight.

Supervision

All resident doctors said that supervision was good and support was available, saying they were getting a good balance of supervision and learning.  Although supervision was good, resident doctors would be appreciative if there was more time to have feedback. Resident doctors found peer feedback valuable as well as educational and clinical supervision, and also welcomed feedback from midwives and nurses in gynaecology.

GAU

The gynaecology assessment unit was raised again as a problematic setting, and resident doctors thought that it wasn’t suitable in layout and function to see the gynaecology patients, and could be better organised and better staffed.  Again, only having one exam room was problematic.  The resident doctors agreed that they thought clearer protocols for referral from A & E to GAU would improve the service demands. There was currently working ongoing to review the referrals process.

Handover

Again, the handovers were described as good and systematic in obstetrics and on the labour ward, but that the handover on the gynaecology ward was variable as each consultant conducted handover differently.  Resident doctors again commented that it wasn’t very coordinated and there was the potential for information to be missed.

Educational resources and facilities

There were no issues with the library and educational resources but resident doctors were concerned that they didn’t have a private space available to work in, conduct private discussions and attend MS Teams meetings for example.

Equality, Diversity and Inclusion (EDI)

All resident doctors said that working relationships were good in the trust, that there were no EDI issues and patients were treated with dignity and respect, apart from the point made earlier regarding lack of suitable space in GAU.

Domain 2 Educational Governance and Commitment to Quality

Incident reporting

The panel asked about the incident reporting process and learning and feedback from incidents.  Resident doctors confirmed that there was a process to learn from incidents and there was a perinatal mortality meeting where all cases were reviewed, but confirmed that resident doctors were often too busy to attend.  All resident doctors agreed that they were comfortable with reporting and received feedback after doing so. E-mails were sent by the trust regarding lessons learned and there were also safety huddles taking place regularly.

Recommendation of placement

All resident doctors were asked if they would recommend their post and what in their view required changing.

All said that they would recommend their post but recommending the following changes;

• Organisation of GAU
• Private space to be made available for resident doctors to have meetings and work away from the clinical setting.
• More learning regarding early pregnancy scanning & access to the simulator scanner.

Supervisors (O&G)

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, without a cap. All supervisors confirmed that they had met with their supervisee regularly.

Supervisors said that the trust were supportive but also recognised that the trust were facing challenges.  Supervisors said there was a desire for change from the management.  An example of this was the maternity improvement work with a scrutiny on culture and improving relationships. 

All confirmed that they had time for their own development and had an educational appraisal. When asked what they would change educationally, the comment was made that more opportunity for management experience would be valuable, e.g. attending governance meetings. More use of simulation in teaching would also be beneficial.

Supervisors were supportive of the needs of the resident doctors and understood their training needs, and were meeting regularly with their supervisees to discuss training needs. The panel fed back that from foundation to ST2,  the system of allocating opportunities appeared to be more ad hoc, and the supervisors explained that there was a template for GP and specialty but not for foundation.  The panel recommended that they share this template.  The panel were concerned that if ad hoc, the risk was that not every resident had their training needs met.

The supervisors were committed to supervising their resident doctors and thought that resident doctors were not asked to work beyond competencies and wouldn’t ask them to consent for a procedure they weren’t comfortable with.  Supervisors had asked resident doctors to escalate any incidents where they had been asked to consent for an interventional radiology procedure.

They also shared their concerns regarding the GAU, and acknowledged that the gynaecology handover could be improved.  The supervisors also supported the resident doctors request for their own space.

General surgery

We met with a group of resident doctors on a general surgery rotation including foundation, core and specialty resident doctors up to ST4

• Domain 1: Learning environment and culture
• Domain 3 Developing and Supporting Learners
• Domain 5: Delivering curricula and assessments

Induction

Induction was described as variable and some resident doctors said that the local induction to general surgery wasn’t comprehensive enough to prepare them for their roles.  One Foundation doctor gave an example of starting their rotation on nights, holding the bleep on this shift and being unaware of local procedures, e.g. how to order blood cultures.  There were seniors they could contact to support but they were also new to the rotation. There was no induction to sub specialties that were covered on call.

The majority of foundation doctors had attended a trust induction which had included clinical skills, followed by some shadowing and the completion of mandatory training.

Training experience  

Foundation doctors described their training experience and allocation of jobs, which were picked up from each ward round and noted in a book.  There wasn’t always a ward round every morning, so they relied on a written record to pick jobs up. Foundation doctors were also required to see outlying patients throughout the hospital.

If foundation doctors required support they called the registrar who had seen the patient on the ward round and if they couldn’t get hold of them, they would contact the on call registrar.  Support was available, but it could be challenging to access support at busy periods.

Foundation doctors described feeling overwhelmed covering up to 80 patients at night.  The panel asked what support was available and there was only a general surgery ‘SHO’ or a registrar in critical care outreach who were supportive.  There appeared to be a reluctance to call the on call consultant.

The panel weren’t clear about the structure and process relating to the learning environment.  For example, some resident doctors were ward based, yet the on call team was team based, which the resident doctors said led to confusion regarding responsibilities. An example was given of a foundation doctor who was ward based but held the bleep, but wouldn’t have seen any of the on call patients. It appeared that the lack of clarity and confusion meant that training opportunities were not optimised and feedback opportunities impacted negatively.

On call responsibilities also included oversight of the vascular and orthopaedic wards and no induction had been provided for these other specialties.

There appeared to be a disparity in training opportunities. Foundation doctors had limited exposure to theatres with approximately 2 allocations in 4 months, while core resident doctors received adequate training but specialty resident doctors had specific unmet training needs, such as laparotomy experience or an endoscopy list, and a low number of clinic allocations.

Foundation doctors said that they weren’t often able to attend local teaching due to work pressures, but could attend regional foundation teaching unless they were on call.

Rota

The majority of resident doctors agreed that service provision dominated, and the rota wasn’t organised to maximise training opportunities. It wasn’t clear to the panel if this was due to the recent changes in the rota, to include cover for urology. There was a rota coordinator but resident doctors said they weren’t sure how to escalate any concerns regarding the rota. Resident doctors commented that the rota worked for service provision rather than training.

Supervision

All resident doctors said they had met with their educational supervisors, however, there was limited time for feedback from clinical supervisors due to service pressures and resident doctors said they required more feedback. 

Equality, Diversity and Inclusion (EDI)

The panel asked about working relationships, and resident doctors said that the relationships between doctors in training were good but that there could be some tensions with doctors from urology and radiology.  The panel asked about culture in theatre, and this was described as positive.

One resident doctor said they had been shouted at by an on call consultant in general surgery, in front of other people, instead of having been given private feedback.  The panel asked if the resident doctor knew how to escalate this, and they did say they would speak to their supervisor.

Several resident doctors described the allocation of training opportunities as unfair, and said there was favouritism in play. They had the perception that learning wasn’t encouraged and a specific group of registrars was favoured.  One resident doctor said that they didn’t feel they were viewed as ‘somebody that needed to learn’.  One example was given of a theatre slot being given to another registrar who wasn’t scheduled to be part of the list according to the original theatre list.

Domain 2 Educational Governance and Commitment to Quality

Incident reporting

Resident doctors seemed to be unclear regarding the incident reporting process and feedback mechanisms.  Two resident doctors said that they had reported incidents but had not received any feedback.  There had been a session planned regarding datix and incident reporting but this had been cancelled.

Resident doctors also seemed to be unaware of freedom to speak up guardians.

Recommendation of placement

All resident doctors were asked if they would recommend their post and what in their view required changing. Only 2 core resident doctors said that they would recommend their posts.

The following comments were made regarding the areas that required improvement.

• Have a better organised system so that there wasn’t such a confusing mix of ward and team based responsibilities, and on call responsibilities were clear.
• Have a fairer rota and system for allocating training opportunities
• Improve the processes for looking after outlying patients, in vascular surgery in particular.
• Service provision was impacting on feedback.

Supervisors (general surgery)

Domain 4 Developing and Supporting Supervisors

The panel explained why the visit was taking place and asked supervisors if they felt supported, what works well for them and if structures worked for them.  All supervisors confirmed that they received an allowance for supervision, but that it was never enough time.  Supervisors confirmed that they did have time to sign off work based assessments.

Supervisors said that they had an open culture, made time for resident doctors and although it could be challenging completing assessments when busy, they found time.  They said that they recognised that resident doctors all have different training needs, and held an initial meeting with their resident to establish training needs.

The panel asked supervisors for their interpretation of the negative outliers in the GMC survey, and fed back that the majority of resident doctors said that feedback and contacting seniors for support was an area that could be improved, along with the allocation of training opportunities. Supervisors acknowledged that there was work to do to improve and cited service pressures as partly responsible and the tension between service and training.

Supervisors said that they were taking into account training requirements, and said that favouritism wasn’t in play.  The panel asked if one interpretation for the accusation of favouritism, could be that resident doctors weren’t clear about the way opportunities were allocated.

Supervisors responded that they were keen to improve training, but weren’t getting enough specific information on what requires improvement, and it might help them to observe a similar department in a different hospital.

Supervisors suggested a number of ways that the training experience could be improved for all;

• Secretarial support
• Rota support
• Contact numbers for juniors.
• More level 1 doctors would be helpful. There had been 15 foundation doctors previously, and there were now 13 and they had to cover urology.  

Areas that are working well

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Fiona Lowndes, Quality Support Manager
Review lead: Professor Simon Carley, Associate Postgraduate Dean
Date approved by review lead: 22 January 2025

NHS England authorised signature: Dr Raghu Paranthaman, Deputy Dean
Date authorised: 23 January 2025

Final report submitted to organisation: 23 January 2025

Publication reference: PRN01548