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Executive summary
Feedback from general surgery resident doctors has improved since our last visit however some improvements are still needed. Some areas of improvement include changes to rota management, removing F1 resident doctors from the rota at night and meeting minimum staffing numbers.
Foundation resident doctors remain unhappy in Trauma and Orthopaedics (T&O) despite the best efforts of the head of service. Overall foundation resident doctors described their time in T&O as a negative training experience.
Main issues that remain in general surgery:
- Induction – Resident doctors reported that induction does not cover the different wards and specialities they are going to be covering which would help.
- Handover – It was reported that F1 resident doctors do not have a handover in the morning. Educators advised us that a project is currently underway to address this.
- Support and supervision – Feedback around senior support varied across the surgical departments. Foundation resident doctors continue to raise their concerns about covering medical issues on the surgical wards.
- Teaching – It was reported that foundation resident doctors are unable to attend teaching due to cover needed on the wards.
Main issues that remain in T&O:
- Support, supervision and ward rounds – It was reported that a patient is seen by a consultant on the first and second day of admission but may not be reviewed by anyone more senior than an F2 resident doctor for up to 30 days, depending on their length of stay following the initial review.
They also reported being left to review the patients on their own with no consistent escalation processes in place if they need support managing medical concerns.
- Workload – It was reported that weekend staffing levels at night and weekends are inadequate, leading to delays in F2 resident doctors responding to ward calls because they are at a trauma call. Educators however did clarify that if they are busy on the wards they are not expected to attend the trauma calls.
- Teaching – Challenges were reported in finding cover to attend teaching sessions which has contributed to resident doctors feeling like they have ‘not learnt anything’ in T&O apart from when they are on call.
- Facilities – It was reported that they still have no dedicated space to work in.
Based on the minimal progress made against previous mandatory requirements, the Intensive Support Framework (ISF) category 3 will remain unchanged. Due to the trust being sent a pre- enhanced GMC monitoring letter previously we will discuss the outcomes with the GMC to determine if any additional next steps are required.
We will be requesting an update to the trust improvement plan, and a further visit will take place to review progress in 2025.
Review overview
Background to the review
Due to the review findings at the last visit and lack of progress made in general surgery, this item was increased from an Intensive Support Framework (ISF) Category 2 to an ISF Category 3, and the General Medical Council sent a pre-enhanced monitoring letter. There was no representation from T&O foundation resident doctors from the QMC site at the last visit so the outstanding mandatory requirements from the 5 July 2023 visit remained on the improvement plan.
In summary, the main concerns that still needed addressing from the previous visit were:
General surgery
- Rota – (QMC) It was reported that minimum staffing numbers are not being met
- Handover – (QMC) There did not appear to be an effective handover process in place on the wards
- Support and supervision (QMC) F1s are discouraged to seek help when required
- Induction – (QMC) Further to our visit in July 2023 F1s are still reporting that there have been no improvements to the induction.
- Teaching – (QMC) It is described as a service provision post only, with no training opportunities
Elective orthopaedics
- Rota – (City Campus) Minimum staffing numbers in the rota was also flagged at the city campus as a concern.
T&O – QMC
- Support and supervision (QMC) – Minimum staffing numbers are potentially not being met on the ward and foundation resident doctors reported to the panel that multiple exception reports are being submitted. They described that at times they feel ‘unsafe’ and ‘overwhelmed’. Foundation resident doctors also reported there is not a clear process in place to secure support from senior colleagues when an orthopaedic patient also has conditions requiring input from medicine colleagues.
- Teaching – (QMC) It was reported that they have no protected time to attend teaching.
- Workload – (QMC) Expectations of foundation resident doctors was described as ‘overwhelming’. They reported feeling ‘pressured’ and ‘stressed’.
- Facilities – (QMC) It was reported that they have a computer in an alcove where the patient bell is located which is distracting.
Who we met with
Learners
- Foundation resident doctors in General Surgery (QMC and NCH) and T&O (QMC)
Educators
- Clinical and Education Supervisors
- Head of Service for T&O, QMC
Education team
- Education Centre Manager
- Medical Director
- Divisional Director of Surgery
- Head of Service for General Surgery
- Assistant Head of Medical Workforce
- Deputy Director of Medical Education
Review panel
- Charlie Mackaness, Foundation Head of School (Trent), Education Quality Review Lead
- Eduardo Villatoro, Deputy Foundation School Director (Trent)
- Kerry Olley, Quality Deputy Manager
Review findings
General surgery
Rota
It was reported that minimum staffing levels overall are now being achieved. Foundation resident doctors confirmed that two F1s cover each ward and when there are sickness gaps this is predominantly one F1 and a Physician Associate.
It was reported that there does not seem to be an equal split across the different surgical wards, and on occasion there are more foundation resident doctors on one ward than others. It was acknowledged that this might be due to a lack of awareness across the different surgical wards with regards to gaps in the rota. It was however confirmed that this is flagged if the staffing numbers are below minimum staffing levels.
We were made aware that there is going to be further modifications to the F1 rota for the twilight shifts for the next set of F1s so that there is more cover. The twilight shifts were described as a steep learning curve.
Foundation resident doctors acknowledged that rota management is hard to coordinate and gave examples where they are being called at short notice to cover rota gaps on their self-directed learning days and described this as feeling ambushed. This was discussed during the educator session, and it was acknowledged that there was significant pressure due to staffing numbers, with 25% of their junior population off sick and unfilled locum posts so this was a last resort decision which they agreed not to use again.
F2 resident doctors also reported covering SRU which is a non-surgical ward, with complicated patients. This was discussed at the surgical board meeting and foundation resident doctors will no longer provide cover on non-surgical wards.
Foundation resident doctors in City Hospital reported that they feel they do a lot of out of hours, however, they feel that that there is good cover, and they are well supported.
Handover
It continues to be reported that an effective handover is not in place. It was reported that F1 resident doctors at QMC do not have any handover in the morning. They confirmed on some of the wards they have a nursing handover but on other wards they do not receive any handover. It was however noted in the educator session that a project is currently underway to address this. They are exploring the option of introducing a handover book.
Support and supervision
Foundation resident doctors continue to raise their concerns about covering medical issues on the surgical wards, particularly when the medical issues are more complex and require senior support. Escalation processes are not clear on all the wards.
It was reported that core resident doctors are very helpful, however, the support from higher resident doctors was described as variable at QMC.
Vascular is reported as a supportive department where foundation resident doctors feel valued.
Teaching
It was reported that departmental teaching in City Hospital is good, however, the feedback varied at QMC, and it was dependant on the registrar in that department. It was reported that they believe some ad hoc teaching has been organised at QMC but due to capacity on the wards they haven’t been able to attend. They reported that they have had no structured teaching tailored to the speciality they are in and added that they would find this useful.
It was reported that vascular have introduced additional training.
Induction
Feedback has improved around induction which was described as good, and foundation doctors have protected time to attend. They did report that there is still room for improvement around the specifics of their role and it would help to cover common procedures and post operative processes. They reported that it does not cover the different wards and specialities they are going to be covering which has resulted in them working on wards without having had an induction and with minimal senior support. They also added that the general surgery booklet was sent two weeks after starting in post.
The vascular handbook was again highly praised and said that it would be good if this could be replicated across all the surgery specialties.
T&O – QMC
Support and supervision, ward rounds
It was reported by foundation resident doctors that on calls with higher resident doctors are good, they are adequately supervised and receive good teaching.
Foundation resident doctors reported that on the wards they receive no feedback on performance, have minimal supervision and are expected to manage medical emergencies. They reported being left to review the patients on their own with no consistent escalation processes in place if they need support managing medical concerns. If they contact their core resident doctor, they are told to call the Medical Registrar on-call, who asks them if their seniors have reviewed the patient. This leaves them feeling like no one is willing to help them and unsure on how the situation should be managed. Foundation resident doctors reported that they sometimes feel unsure if they are doing things right without the supervision of senior colleagues. They added that the time taken to do this is having a negative impact on their workload.
This was discussed in length with the educators and during the feedback session it was confirmed that the trust is currently recruiting a resident Middle Grade medical doctor who will be available on the ward for direct access to the medical support required. There are also plans to recruit an extra two T&O consultants to increase the number of ward rounds on weekdays.
Foundation resident doctors reported that the consultant does not include them on their ward rounds which leaves them at a disadvantage.
It was reported that a patient is seen by a consultant on the first and second day of admission but may not be reviewed by anyone more senior to an F2 resident doctor for up to 30 days depending on their length of stay following the initial review. There were continued reports of solo ward rounds from the F2 resident doctors which remains unchanged from the previous visit.
Rota
It was reported that gaps in the rota at QMC are often dealt with the day before despite prior knowledge of this resulting in resident doctors feeling like they are constantly providing cross cover.
No foundation resident doctors attended this visit from City Hospital, therefore, the outstanding mandatory requirement relating to the rota will remain on the improvement plan from the last visit.
Teaching
It was reported by foundation resident doctors that it is difficult to get to their weekly mandatory protected foundation teaching as often that would leave the ward below minimum staffing levels. An example was given where they have managed to attend teaching three times during the placement (out of fifteen). They reported challenges in finding someone to cover them to attend teaching.
Foundation resident doctors advised us that they have not learnt anything in T&O apart from when they have been on call.
Workload
Although resident doctors feel well supported by higher resident doctors it was reported that staffing levels at night and weekends are inadequate. It was reported that this is leading to delays in F2 resident doctors responding to ward calls as they are asked to attend an increasing number of trauma calls. Foundation resident doctors explained that one of them had 11 of these calls in one night (with his registrar). One example reported to the panel highlighted that a stroke patient on the ward did not receive timely care, on a night in which they had five trauma calls and both the Middle Grade and F2 resident doctor on-call had to respond to them. Foundation resident doctors reported that the out of hours (nights and weekends) intensity of work can be unbearable. Educators did report that F2 resident doctors are only expected to go to trauma calls if available, but if they are busy on the ward they were not be expected to attend.
Foundation resident doctors reported that they are all burnt out. They described that there is an increase in sickness due to this and the department is always running on minimum staffing levels of two foundation resident doctors. They added that when they raised this with a consultant, they disagreed that the workload is busy. They reported that even though minimum staffing levels are being met, they still cannot finish on time or get to take all their breaks.
During the educator session it was acknowledged that same day staff sickness issues are still ongoing. There are now two foundation doctors now on the rota and they are also continuing to develop the Advanced Clinical Practice (ACP) program to also support on the ward.
Facilities
It was reported that the foundation resident doctors have no dedicated workspace. They are located near where relatives are and are constantly distracted and asked questions. It was reported as being quite demanding.
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action | Domain(s) and standard(s) |
|---|---|---|
| Support, supervision and ward rounds – T&O It was reported that a patient is seen by a consultant on the first and second day of admission but may not be reviewed by anyone more senior to an F2 resident doctor for up to 30 days depending on their length of stay following the initial review. There were continued reports of solo ward rounds from the F2 resident doctors. | Trust response requested. Trust to clarify the process for senior patient review and the frequency. | IMR1 1.5 |
Mandatory requirements
| Review findings | Required action | Domain(s) and standard(s) |
|---|---|---|
| Rota – General Surgery Minimum staffing levels are being met however it was reported that foundation resident doctors are being sent from one ward to another without access to senior support. | Trust to review senior support available to foundation resident doctors when they are covering rota gaps in a specialty that they have no experience in. | MR1 3.9 |
| Induction – General Surgery It was reported that the inductions do not cover the different wards and specialities that they are going to be covering which would help. | The trust needs to ensure that learners receive an appropriate, effective and timely induction into the clinical learning environment. The trust should adapt inductions, so they cover the different wards/specialties. | MR2 3.9 |
| Handover – General Surgery It was reported that F1 resident doctors do not have a handover in the mornings. It was however noted in the educator session that a project is currently underway to address this. | The trust needs to ensure that effective handovers are in place on the wards. | MR3 1.5 |
| Support and supervision – General Surgery Feedback around senior support varied across the surgical departments. Foundation resident doctors continue to raise their concerns about covering medical issues on the surgical wards particularly when the medical issues are more complex and require senior support. The trust has confirmed recruitment plans are in place to address this and in the interim they will be meeting with the divisional director in medicine to see how they can bridge this gap whilst recruitment takes place. | Trust to review senior support for foundation resident doctors. | MR4 3.5 |
| Teaching – General Surgery and T&O General Surgery It was reported that foundation resident doctors are unable to attend teaching due to cover needed on the wards. T&O – It was reported that if they ask someone to cover for them so they can attend teaching they are told no. They reported that they have not learnt anything in T&O. | Trust to evidence that foundation resident doctors are supported to complete appropriate summative and/or formative assessments to evidence that they are meeting their curriculum, professional standards, and learning outcomes. | MR5 3.7 |
| Facilities – T&O It was reported that foundation resident doctors have no dedicated workspace. | The learning environment should provide suitable educational facilities for both learners and supervisors, including space and IT facilities. The trust should review suitable options. | MR6 1.11 |
| Support, supervision and workload – T&O Foundation resident doctors reported being left to review the patients on their own with no consistent escalation processes in place if they need support managing medical concerns. They reported that even though minimum staffing levels are being met, they still cannot finish on time or take their breaks. | The trust has confirmed recruitment is in progress to recruit a medic to be on the wards to assist with medical concerns and reduce workload for foundation resident doctors so they can leave on time. This will be reviewed at the next visit. The trust should encourage foundation resident doctors to exception report. | MR7 3.5 |
| Workload – T&O It was reported that staffing levels at night and weekends are inadequate, leading to delays in F2 resident doctors responding to ward calls because they are asked to attend an increasing number of trauma calls. Foundation resident doctors reported that the out of hours (nights and weekends) intensity of work can be ‘unbearable’. | Trust to review weekend staffing levels out of hours (nights and weekends) and the trust to clarify and ensure F2 resident doctors are aware that if they are busy on the ward they are not expected to attend trauma calls. | MR8 1.1 |
Recommendations
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
| The trust should review the sharing of good practice across the surgical specialties. Vascular is reported as a supportive department where foundation resident doctors feel valued. The vascular handbook was also highly praised. | 2.7 |
Report approval
Report completed by: Kerry Olley, Quality Deputy Manager
Review lead: Charlie Mackaness, Head of school for Foundation
Date approved by review lead: 3 December 2024
NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean
Date authorised: 18 December 2024
Final report submitted to organisation: 15 January 2025