Executive summary

Overall, resident doctors across both sites of Nottingham University Hospitals (NUH) described a mixed training experience.

All resident doctors spoke positively about the working environment and culture, describing the consultants as supportive and approachable. They described the department as friendly and welcoming and felt they were working in a respectful environment. Those resident doctors that had been at NUH previously reported that there had been measurable improvements to the culture overall.

A significant concern reported by all levels of resident doctors across both sites was the absence of a rota coordinator and an overly complex rota structure with no consultant oversight or supervision. The rota is currently being managed by senior resident doctors on top of their clinical duties. Leave requests were also reported as not being actioned. This situation has significantly negatively impacted morale and the overall learning experience for resident doctors. During the feedback session, we expressed that these current rota arrangements are unacceptable, emphasising the urgent need for college tutor and/or consultant input and supervision and the prioritisation of the appointment of junior doctor administrators/rota co-ordinators across both sites.

There was mixed feedback regarding learning opportunities at Nottingham City Hospital (NCH) with positive feedback regarding obstetric training but a lack of gynaecology exposure and limited access to clinics and theatre sessions. Feedback was more positive from Queens Medical Centre (QMC) with some resident doctors highlighting good opportunities, however they reported that numerous rota gaps limit the opportunities for more junior resident doctors.

There were logistical issues with induction, including being put on a twilight shift directly after induction or a night shift prior to induction. There were reports of delays with rotas and work schedules. These issues were felt to be due to the absence of a junior doctor administrator.  There were also some resident doctors at NCH that felt there was a lack of practical induction within the departments which left them feeling unprepared when starting.

It was reported that postoperative ward rounds for elective gynaecology patients at NCH are being managed by junior resident doctors who reported it can sometimes be difficult to find the correct support when there is a complex case.

Whilst all the resident doctors we asked said they would recommend NUH as a place for treatment, some were less likely to recommend NUH as a place to train due to a lack of learning opportunities and lack of administrative and rota support.

To summarise, the areas to be addressed by the trust are as follows:

• Rota management
• Learning opportunities
• Induction
• Clinical supervision
• Requests for leave

Based on the mandatory requirements that have been identified, notably the poor rota management processes, the panel will be recommending this item is increased from an intensive support framework (ISF) category 1 to ISF category 2 and added to the Quality Improvement Register. A trust improvement plan will be required against the mandatory requirements outlined in this report.

Review Overview

Background to the review

The results for the 2024 General Medical Council (GMC) National Training Survey (NTS) and the 2023 National Education and Training Survey (NETS) showed multiple categories where responses were below the national average at Nottingham University Hospitals (NUH) for resident doctors within Obstetrics and Gynaecology (O&G). To better understand their experience of the clinical learning environment, a learner educator meeting was arranged for 7 November 2024, and we met with all grades of resident doctors in O&G across NCH and QMC.

Who we met with

Learners

• Resident doctors in O&G

Educators

• Clinical and Educational Supervisors in O&G

Senior team

• Director of Medical Education
• Medical Director
• College Tutor
• Postgraduate Quality Manager
• Head of Service for Gynaecology

Review panel

• Dr Robert Powell, Deputy Postgraduate Dean
• Dr Farah Siddiqui, Deputy Head of School, O&G
• Dr Humera Ansar, Training Programme Director (South) O&G
• Dr Anjla Sharman, Head of School for General Practice
• Sarah Wheatley, Quality Deputy Manager

Review findings

Environment and culture

The resident doctors spoke positively about the culture within O&G and described the consultants as supportive and approachable. They felt it was a good educational environment with several consultants demonstrating a passion for teaching. Whilst some described it as a bit overwhelming when starting, they felt that people were friendly and welcoming and felt they were working in a respectful environment. Those resident doctors who had been at NUH previously felt there had been measurable improvements to the culture overall.

Resident doctors are comfortable to raise concerns and are aware of the Freedom to Speak up Guardian. All resident doctors have been allocated educational supervisors and spoke positively about the support they provide. The educators reported feeling valued in their roles and have time reflected in their job plans.

Rota

The organisation and lack of administration for the rota is a major concern for all levels of resident doctors across O&G at both sites. They described the rota structure as complex and difficult to access, with no option to view it from outside of the hospital. Resident doctors reported often arriving at work only to find they have been scheduled somewhere unexpectedly. With no dedicated rota coordinator or junior doctor administrator in post, the rota is currently coordinated by senior resident doctors who manage this on top of regular clinical duties. There is minimal time allocated for this, and it was reported that it can take 10-15 hours a week to coordinate due to its complicated format.

Resident doctors reported that the rota for the upcoming week is sent out by WhatsApp message at the weekends, often as late as Sunday pm. The resident doctor organising the rota is also assigned as the troubleshooter who manages daily rota gaps on top of clinical responsibilities, including managing the labour ward. It was reported that when rota gaps are reported to HR there is often no response.

Overall, they described the rota issues as a long-standing problem which is now ‘out of hand’. There is no consultant formally assigned to oversee or assist with the rota or annual leave and study leave requests are not getting approved. This is having a significant negative impact on morale and the learning experience.

The educators recognised the issues with the rota and advised that e-rostering is being rolled out across the trust with O&G being prioritised. However, they also recognised there is more work to be done before the weekly rota can be online. They also reported that they are reviewing the trouble shooter role. 

Learning opportunities

Junior resident doctors at NCH reported positive learning opportunities in obstetrics, feeling increased confidence in their roles. However, they all expressed concern over the lack of gynaecology training at NCH as acute gynaecology services are located on the QMC site.

Higher resident doctors at NCH also described a positive experience within obstetrics, highlighting that the obstetrics training is very well organised. However, they too reported insufficient gynaecological experience. Some higher resident doctors reported that they had only attended one gynaecology theatre session so far in the rotation and had to actively request opportunities to attend gynaecology clinics and triage. The limited exposure to gynaecology is causing concern about their ARCP progression. Additionally, there were reports of resident doctors coming in on days off and taking extra on call shifts to complete advanced training skills modules (ATSM) and special interest training modules (SITMs) due to there being a lack of slots. In the educator session we heard examples of one gynaecology consultant having had no resident doctors allocated to their lists for several months which was considered to be a missed opportunity for valuable training experiences.

Higher resident doctors felt there was a lack of understanding that resident doctors Certificate of Completion of Training (CCT) is in both obstetrics and gynaecology. The resident doctors get split into gynaecology oncology who get multidisciplinary team (MDT) working and opportunities for theatre sessions, or obstetrics, who will be left to cover the labour ward. These concerns have been escalated to the college tutor.

GP resident doctors were less positive about their learning experiences, feeling that they were gaining minimal GP related skills, with limited clinics and a focus mainly on service tasks such as To Take Outs (TTOs) and discharge letters. It was also reported that GP resident doctors are having difficulties with getting assessments such as CPD and MiniCEX signed off, due to not working with a consultant long enough to get assessments completed. Additionally, any feedback they receive mainly comes from the midwives as this is who they primarily work with. The lack of curriculum outcomes has been raised with the training programme director and we heard in the educator session that there is now a consultant nominated to be a liaison person, and monthly meetings have been organised to address training issues.

Whilst resident doctors confirmed that Practical Obstetric Multi-Professional Training (PROMPT) is overseen by a consultant and invitations to this training are sent every year, they reported a lack of accessibility for basic life support (BLS) training with no reminders being sent out when training expires and no contact from the resuscitation team when enquiries had been made. 

Junior resident doctors at QMC reported that numerous rota gaps are limiting their ability to attend clinics. When they are allocated to clinics, they are often called back to the wards to cover staff shortages. Despite this, they described the clinic experience as beneficial when they were able to attend. GP resident doctors found the gynaecology triage valuable for their training but felt that the labour ward offered limited relevance to their GP related learning.   

Higher resident doctors at QMC shared positive feedback highlighting good learning opportunities and an overall positive training experience. However, they did report some missed opportunities for valuable learning due to being unable to participate in serious untoward incidents (SUIs) meetings. They reported that this was due to a lack of response from the governance team when requesting to be involved.

Induction

At NCH, whilst some resident doctors appreciated the comprehensive information provided during the induction day, some felt there was a lack of practical induction within their departments. GP resident doctors reported feeling particularly stressed at being asked to cover multiple areas without adequate preparation, feeling unprepared to manage post-natal reviews and benign gynaecology patients. It was felt that more practical support at the start would have improved confidence and understanding of key clinical indicators.

At QMC the induction was described as useful, but issues were reported with resident doctors being assigned to twilight shifts immediately after a full day of induction and some doctors were scheduled to work the night shift prior to induction. Many were unsure where key departments such as acute gynaecology were located, and some suggested a map would have been helpful. Despite these issues resident doctors appreciated the friendly environment and good registrar support that carried on after induction. 

Resident doctors across both sites highlighted communication issues due to the absence of a dedicated rota coordinator or junior doctor administrator which caused delays with rota allocations. There were also reports of work schedules being sent out late with incorrect contracted hours resulting in incorrect pay.  

Workload

Resident doctors at NCH described the workload as variable with the intensity of on calls being a struggle on labour ward and days on call being especially busy. It was reported that post operative ward rounds for elective gynaecology patients are being managed by junior resident doctors. Despite feeling capable of managing them, they did raise that when there is a more complex case it can be sometimes difficult to find the right support and are expected to contact the surgical team or ask the labour ward registrar who is often busy. This has been escalated to the consultants who are looking to make changes to elective gynaecology.

Resident doctors at QMC reported that workload was dependent on which shift they are on.  They reported that triage can get busy, and days on the weekend are very busy, however, most managed to take breaks and leave on time. In some instances, it was felt that it would be useful to have an increased workload to increase the training opportunities due to the number of doctors competing for the same training. It was also reported that less than full time (LTFT) rotas are often unbalanced with blocks of on call shifts scheduled together.

All resident doctors are aware of how to exception report, and this has been encouraged by the Director of Medical Education, however, it was reported that this is rarely utilised.

Areas that are working well

Areas for improvement

Mandatory requirements

Report approval

Report completed by: Sarah Wheatley, Quality Deputy Manager
Review lead: Dr Robert Powell, Secondary Care Deputy Postgraduate Dean, East Midlands
Date approved by review lead: 3 December 2024

NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean
Date authorised: 9 December 2024

Final report submitted to organisation: 15 January 2025