Executive summary
On 1 October 2024 face to face meetings were held with Princess Alexandra Hospital NHS Trust (PAHT) trainees and trainers in Anaesthetics, Medicine, Emergency Medicine, Paediatrics and Surgery to review the impact of the open improvement plan and to evaluate the progress of improvements following the trust entering the General Medical Council (GMC) enhanced monitoring process in December 2022.
The report has been written in a manner to preserve the anonymity of trainees and includes commendations for areas of good practice as well as educational requirements that need to be addressed. NHS England Workforce Training and Education (WT&E) will review and update the open improvement plan to reflect feedback from these meetings, and engagement outcomes, alongside relevant quality intelligence that will inform next steps for the GMC enhanced monitoring process.
The meetings demonstrated many areas of good practice which include:
- There is good engagement with NHS England WT&E Education Quality processes, and all meetings were well organised and well attended.
- Many trainees and trainers noted a positive shift in the culture of the trust.
- Most trainees and trainers feel the hospital is friendly, and colleagues are supportive.
- Trainers from all areas feel supported by the trust education team, the Director of Medical Education (DME), the Guardian of Safe Working (GOSW), and Medical Director (MD). They were praised for their proactive approach to managing issues and changing the educational culture across the trust. Educational governance processes across the trust are reported to be known and well embedded.
- Trainers reported the DME is very good at sharing information and a WhatsApp group is utilised to promote education training opportunities. The new education centre facility was also praised.
- Anaesthetics, Paediatrics and Surgery trainees were positive about their departments and the culture at the trust. These groups report they are well supported, receive training, and can achieve curriculum requirements.
- Interprofessional relationships were felt to be helpful, with support from nurses, midwives and allied health professionals praised by trainees across programmes.
- All trainees were aware of Datix and Exception reporting processes and reported these are covered in induction (though some areas felt more able to complete these).
- Trainees and trainers across programmes report there are good learning opportunities available at the trust.
- The trust MD, DME, non-executive director and Guardian of Safe Working (GOSW) delivered a presentation sharing their learnings following GMC Enhanced Monitoring which outlined a senior led, trust-wide approach to address issues, and work to enable a culture that fosters openness and transparency.
PAHT is to be congratulated for the significant progress noted in multiple areas and for taking an innovative approach to managing many of the challenging educational issues facing the trust.
However, there are still areas of concern that need to be addressed, including two potential patient and trainee safety risks identified which required an immediate 5-day response:
- Acute medicine trainees report they are frequently unable to access consultant support to review patients overnight who have deteriorated. They consequence of this was a lack of timely onward tertiary referrals for patients with critical needs. Trainees report putting requests for support on ‘Alertive’ with no responses for several hours. Trainees additionally reported that there was a lack of clarity over the referral pathways. They acknowledged that the lack of clarity was in part related to patient postcode (which potentially directs patients with similar diagnoses to different tertiary centres). However, they were unable to escalate patient care even when the appropriate tertiary centre could be identified, leaving patients in PAHT who they felt should have been referred and transferred onwards.
- Trainees from a number of specialties reported that the hospital was understaffed at night and felt this was regularly to unsafe levels.
- Acute medicine trainees reported that they were unclear of what safe staffing levels were overnight, particularly following a reorganisation of their rota to include a twilight shift with an apparent (to them) reduction in overnight staffing and variable filling of rota gaps.
- Paediatric trainees reported unsafe staffing levels as a consequence of managing patients in split sites across the trust when one of the trainees on was very junior (F2).
- Anaesthetic trainees and consultants reported the lack of automatically provided airway support (ODP or appropriately trained senior nurse) as an integral part of a cardiac arrest team led to safety concerns for patients. Anaesthetic staff also reported the lack of a fourth tier of resident cover at night resulted in safety concerns, particularly when the trainees on the lower tiers were very junior.
The trust provided responses to the immediate concerns within the 5-day period. NHS England WT&E was assured the actions identified mitigate the immediate trainee and patient safety concerns and have identified within the report where we require further actions to give full assurance regarding these issues. In the meantime, NHS England WT&E recommend the trust continue to closely monitor the success of implemented actions.
Though improvements were noted in many areas, the meeting feedback also demonstrated further challenges in the learning environment, many of which are longstanding and identified as actions within the current improvement plan indicating a revised approach may be required to ensure improvements in these areas are embedded and sustained:
- Medicine trainees perceive training is not valued and is impacted by inadequate staffing, with service provision taking precedence over training needs and would not recommend the trust for training as they feel they are unsupported and do not receive adequate training opportunities.
- Female trainees in Medicine, Emergency Medicine and Surgery reported they had experienced sexist behaviours (being challenged and/or excluded), with issues in surgery escalated and the situation supported and dealt with by the department. In the Emergency Department, trainees felt there were issues with preferential treatment more than sexism. There were mixed feelings amongst trainees regarding experiences of sexism and also favouritism not based on sex and/or race in Emergency Medicine.
- Some Medicine trainees (both foundation and higher) and foundation/core Emergency Medicine trainees felt discouraged from exception reporting with a perception that some supervisors view exception reports as a negative reflection on themselves.
- Many Medicine trainees felt induction was insufficient with no input from some sub-specialties. There was report of no GIM on-call induction, with some trainees saying they did not receive appropriate log-ons and/or access to systems before starting shifts.
- Medicine trainees report service pressures curtail access to clinics and regional teaching, and they are required to come in on days off in order to achieve clinic requirements. Emergency medicine foundation and ST1 Emergency medicine trainees report they rely on night shifts to complete assessments with the help of registrars, but higher ST trainees are challenged to complete assessments during shifts.
- Medicine trainees report it is difficult to access annual leave despite forward planning as the rosters were not yet released beyond December. They felt the rota management is challenging in many respects.
These areas need to be actioned and monitored against outcomes to ensure quality improvements are embedded and sustained. NHS England WT&E will continue to work collaboratively with PAHT to agree milestones and actions against the educational requirements within the revised improvement plan.
Review overview
Background to the review
The review meeting was implemented following existing concerns regarding the clinical learning environment within Anaesthetics, Emergency Medicine, Medicine, Paediatrics, and Surgery, to review the clinical learning environment, and to gauge the success of improvement strategies implemented to date. The review meeting has been conducted in accordance with the NHS England Educational Quality Framework Domains and Standards for Quality Reviews.
The Princess Alexandra Hospital NHS Trust (PAHT) has an active improvement plan in place and has been on the Education Quality Improvement Register since February 2020 for Medicine and Medicine specialities. In April 2021, new concerns were raised through the GMC National Training Survey (NTS) 2021 results for Anaesthetics, and General Surgery, and in recognition of concerns identified across multiple programmes, in December 2022 the GMC placed the trust into their enhanced monitoring programme. Paediatrics was added to the concerns following a high number of red outliers within the 2023 GMC NTS results. At the time of the meetings the Quality Improvement Register risk rating for the trust was applied trust wide at 20, Intensive Support Framework 3.
A programme of regular support for improvement is being implemented, including regular reviews of the trust progress against the GMC and NHS England WT&E improvement plan requirements. The support is ongoing and includes quarterly supportive meetings between the trust and NHS England WT&E as well as quarterly stakeholder partnership meetings in collaboration with the GMC, CQC, and Hertfordshire and West Essex Integrated Care Board.
The purpose of this engagement meeting was to triangulate the experiences of anaesthetic, emergency medicine, medicine, paediatric and surgery trainees and hear directly about their perception of progress and the support provided to them.
Evidence utilised
- NHS England WT&E internal governance documentation which includes feedback from regular meetings, improvement plan monitoring, and reports from previous engagement meetings.
- GMC National Training Survey 2024, and National Education and Training Survey 2023 outcome.
- CQC Inspection Report 16 June 2023
Who we met with
Trainees and Trainers
- Anaesthetics:
- 9 higher trainees including ACCS
- 7 Anaesthetic trainers
- Emergency Medicine:
- 12 higher trainees including 3 LEDs, 5 ACCS
- 6 Emergency Medicine trainers, including division lead
- Foundation/GP trainees (representative trainees in posts across Anaesthetics, Emergency Medicine, Medicine, Paediatrics and Surgery):
- 3 GPSTs
- 17 FY1
- 8 FY2
- 18 GP and Foundation trainers from across divisions, including FTPDs
- Medicine:
- 13 higher Medicine trainees including 2 LEDs
- 9 Medicine trainers
- Paediatrics:
- 8 higher paediatric trainees including 3 LEDs
- 12 trainers, including College Tutors
- Surgery:
- 6 higher surgery trainees including 2 LEDs
- 10 surgery trainers, including department lead and college tutor
Trust presentation
A presentation was delivered by senior trust representatives to share learning from the experience following GMC Enhanced Monitoring presenters included:
- Dr Fay Gilder, Medical Director
- Dr Preethi Gopinath, Director of Medical Education
- Darshana Bawa, Non-Executive Director
- Dr Salma Al-Ramadhani, Guardian of Safe Working
High level outcomes were communicated to the senior trust leadership team following the engagement meetings.
Review panel
Education Quality Review Lead:
- Marjorie Casey, Education Quality Manager (attended Surgery, GP/Foundation, and Emergency Medicine)
- Ryan Collins, Quality Intelligence Project Manager (attended Anaesthetics, Paediatrics, and Medicine)
Patch Dean:
- Dr Rowan Burnstein, Deputy Postgraduate Dean/Patch Dean
Speciality Expert:
- Anaesthetics:
- Dr Emily Simpson, Acting Head of School of Anaesthetics,
- Dr Eschtike Schulenburg, Anaesthetics Training Programme Director
- Emergency Medicine:
- Dr Pawan Gupta, Head of School of Emergency Medicine,
- Foundation/GP:
- Mr Shiva Dindyal, Deputy Foundation School Director,
- Ms Sarah-Jane Walton, Foundation Training Programme Director,
- Dr Jayne Hiley, General Practice Training Programme Director
- Medicine:
- Dr James Edwards, Head of School of Medicine,
- Dr Rowan Burnstein, Deputy Postgraduate Dean/Patch Dean
- Paediatrics:
- Dr Vasanta Nanduri, Head of School of Paediatrics
- Dr Rowan Burnstein, Deputy Postgraduate Dean/Patch Dean
- Surgery:
- Mr Raaj Praseedom, Deputy Head of School of Surgery
External Speciality Expert:
- Tulsi Patel, GMC Education Quality Assurance Programme Manager (attended Anaesthetics, Paediatrics and Medicine meetings)
NHS England Education Quality Representative(s)
- Agnes Donoughue, Education Quality Coordinator (attended Anaesthetics, Paediatrics and Medicine)
- Hayley Peacock, Education Quality Officer (attended Surgery, GP/Foundation, and Emergency Medicine)
Review findings
1. Learning environment and culture
Trainees and trainers across programmes felt there were good learning opportunities at the trust and a variety of cases. Most trainees we met with were positive about their experiences, with Anaesthetic, Paediatric, and Surgery trainees reporting a good culture within the trust and in their departments. Higher Emergency Medicine trainees were also largely positive about their experiences at the trust, though some felt the culture depends on personal relationships, with some extradepartmental colleagues needing to be reminded of civility. They noted the usage of the ’Alertive’ app for referrals with some trainees feeling the use of the app is helpful if a speciality was being rude or reluctant to accept a referral and felt people are more polite when seniors are included in the chat.
Medicine trainees were less positive about the learning environment and culture with some describing the culture as toxic; this was particularly felt to be the case in Acute Medicine. They were also less positive about the ‘Alertive’ app. Medicine trainees perceive training is not valued and is impacted by inadequate staffing, with service provision taking precedence over training needs.
Acute medicine trainees report they are frequently unable to access consultant support to review patients overnight who have deteriorated (RQ1). The consequence of this was a lack of timely onward tertiary referrals for patients with critical needs. Trainees report putting requests for support on ‘Alertive’ with no responses for several hours. Trainees additionally reported that there was a lack of clarity over the referral pathways. They acknowledged that the lack of clarity was in part related to patient postcode (which potentially directs patients with similar diagnoses to different tertiary centres). However, they were unable to escalate patient care even when the appropriate tertiary centre could be identified (RQ2).
Trainees from a number of specialties reported that the hospital was understaffed at night and felt this was regularly to unsafe levels of care, and consequently felt unsafe themselves:
- Acute medicine trainees reported that they were unclear of what safe staffing levels were overnight, particularly following a reorganisation of their rota to include a twilight shift with an apparent (to them) reduction in overnight staffing and variable filling of rota gaps (RQ3). Trainees felt with the twilight shift that the daytime staffing suffered, and often people who were rostered for twilight to support the front door (and reduce the number waiting to be seen by the night team) were often pulled to the wards instead due to understaffing.
- Paediatric trainees reported unsafe staffing levels as a consequence of managing patients in different areas/buildings on the main site when one of the trainees on was very junior (F2) (RQ4).
- Anaesthetic trainees and consultants reported the lack of automatically accessible airway support (an ODP or appropriately trained senior nurse), as an integral part of a cardiac arrest team leading to safety concerns for patients (RQ5). Anaesthetic staff also reported the lack of a fourth tier of resident cover at night resulted in safety concerns, particularly when the trainees on the lower tiers were very junior (RQ6).
Both Emergency Medicine and Surgery trainees and trainers noted some challenges with interdepartmental working at trainee level across the departments, reporting some of the behaviours are felt to be due to pressure. An internal professional standards procedure has recently been modified and actioned and the departments will audit how much these changes behaviours in practice (RC1).
Female trainees in Medicine, Emergency Medicine and Surgery reported they had experienced sexist behaviours (being challenged and/or excluded), with issues in surgery escalated and the situation supported and dealt with by the department (RQ7). In the Emergency Department, trainees felt there were issues with preferential treatment more than sexism. There were mixed feelings amongst trainees regarding experiences of sexism and also favouritism not based on sex and/or race in Emergency Medicine, but more related to equity of access across all training grades. Trainees suggested the perceived inequalities could be addressed with a shift rota allocating doctors of different grades to the different areas (e.g. resus, majors, etc) rather than just for Paediatric ED (RC2).
All trainees across programmes were aware of the GOSW and Freedom to Speak Up Guardian and the process to raise concerns and exception reports. Trainees in Anaesthetics, Paediatrics, and Surgery report they are comfortable escalating concerns and receive feedback. However, Medicine and Emergency Medicine foundation/core doctors reported they felt issues are too common and Datix is too onerous to report every situation (takes too long, happens too often). foundation trainees did not feel they always received feedback on Datix’s or details about the next steps. Many foundation trainees had not ever raised Datix or were choosing not to raise Datix due to the time it takes to complete them and the lack of belief that anything would be done. Higher Medicine trainees feel they raise the same issues repeatedly with no progress made (RQ8).
Some Medicine (Acute) trainees feel exception reporting is discouraged, though they are aware of the process and feel this is well covered in induction. They indicate seniors/consultants believe exception reporting is a negative reflection on themselves, and therefore trainees are reluctant to submit as it will get back to them; there is reluctance to submit exception reports without explicit approval (RQ8). Trainees stay late as they do not perceive it is safe (for patient care) to leave on time. In contrast, medicine trainers report they strive to enable trainees to leave on time and to exception report when they need to stay late.
2. Educational governance and commitment to quality
As part of the day of the engagement meetings, the trust was asked to share their learnings following GMC Enhanced Monitoring. In response to this, the MD, DME, non-executive director and GOSW delivered a presentation that outlined the steps taken to review processes and enhance educational governance, including the appointment of a non-executive director with medical education within their portfolio. The presentation outlined the executive oversight of medical education, educational governance processes, steps taken to enhance educator development, and to enable and elicit trainee feedback and further actions. The trust outlined a senior led, trust-wide and collaborative approach to address issues, and work towards enabling a culture that fosters openness and transparency. The approach focused on seeking and acting on trainee feedback (and trainee involvement), while simultaneously focusing on developing educators and promoting good practice. The trust demonstrated processes they used to monitor the impact of work they were doing internally. The drive for trainee feedback was evidenced in the trainee response rate to the GMC NTS which was amongst the highest in the region. The presentation acknowledged there is still significant work to be done, but there is much to be learned from what has been accomplished. NHS England WT&E and the GMC commend the trust for the achievements made.
3. Developing and supporting learners
Anaesthetic, Paediatric, and Surgery trainees felt they received an appropriate induction and are prepared and supported when on call. In contrast, many Medicine trainees felt induction was insufficient with no input from some specialties, and reports of no GIM on-call induction. Some trainees did not receive appropriate log-ons and access to systems before starting shifts (RQ9).
Foundation and GP Paediatric trainees did not feel prepared for their first overnight shifts and noted that overnight there is only one registrar covering multiple areas across the hospital site. It was noted that help was available in emergencies, and that midwives and nurses are supportive, but the situation was stressful and felt unsafe (RQ4).
Foundation and GP medicine trainees felt supported on call by registrars, but did not feel consultants were always available when needed (RQ1). Many departments were reported to rely on external locums, with foundation/core trainees perceiving they are sometimes competing for learning opportunities. Acute Medicine (all levels) trainees observed some locum consultants use nonstandard care plans, which they felt contradicted NHS standard guidelines. Some foundation trainees in Acute Medicine do not trust the patient care provided by locum consultants and report they trusted registrars more than locum consultants. They felt when issues were raised with locum consultants they are not listened to as foundation doctors. They noted that registrars would confirm their plans were correct but would not challenge locum consultants due to seniority (RC3).
Rota management in Anaesthetics and Surgery was praised, with Anaesthetics reported to be excellent and the rota manager specifically praised and felt to be supportive. However, anaesthetic staff also reported the lack of fourth tier of resident doctor cover at night resulted in safety concern, particularly when trainees on the lower tiers were very junior (RQ6). The trust provided an update and clarified the anaesthetics department recorded two Datix reports relating to staffing in the last 6 months, and will continue to monitor this and encourage colleagues to Datix report to further evidence these concerns.
The rota was felt to be challenging in other areas with paediatric foundation and GP trainees reporting the rota is very on-call heavy and that the rota coordinator is not sympathetic to trainee requirements. Higher paediatric trainees felt there are needed improvements in staffing required and many rota gaps (RQ4). They acknowledged there are many less than full time trainees in the department which can be challenging. Paediatric consultants are reported to be fully staffed, with no vacancies in the consultant rota. Emergency Medicine trainees feel the rota is onerous without consideration of shift patterns (i.e. may start the week on mornings and move to late shifts in the middle of the week resulting in feeling very tired at the end). They reported that self-rostering was suggested, but there was wide resistance to this. Medicine trainees report it is difficult to access annual leave despite forward planning as the rosters were not yet released beyond December. They felt the rota management is challenging in many respects.
Medicine trainees reported short staffing updates to rotas are often slow, with known gaps unfilled until the day before. Medicine trainees report the change to twilight shits is supportive and the rate of on call frequency has improved. However, weekends are felt to be unsafe and trainees report calls are not responded to, and they are sometimes expected to act in roles beyond their scope of training (RQ1). Some felt a change in medical staffing would help, with a change back to a firm-based system. There was a difference in perception of rota from Medicine trainers, with educators indicating the rota has improved since August, with more consultant support available to support trainees, and a better mix of trainees and trainers. Trainers report they feel able to support trainees to gain skills and increase their competence.
4. Developing and supporting supervisors
Educators across departments feel supported by the Medical Director, the DME and the wider education team, and their divisional colleagues. The new educational centre was praised as a useful resource to the trust and trainers. Trainers spoke positively about the culture of the trust with Emergency Medicine trainers reporting the Medical Director has set up a new consultant development course which supports consultants across departments getting to know each other and in turn supports better professional relationships and an improved ability to support trainees in working across departments.
Most educators reported they have time in their job plans for educational supervision and are renumerated appropriately for this, but many noted funding is not provided for training to International Medical Graduates, Locally Employed Doctors (LEDs) and locums and this can be challenging. Some educators report they could be supervising 2 LEDs for each funded trainee, with some colleagues refusing to take on non-training grades which can create bad will. Most trainers report they can access educator study leave and are able to use professional leave to support ARCPs. However, surgery and anaesthetics trainers report they were required to use study leave to support STCs and ARCPs and were required to move theatre lists to a weekend as they were not given time off to support essential educator activities (RC3).
The hospital was noted to be very busy with an element of ‘burn out’ noted by trainers across some programmes. While the hospital is perceived to be busier than previous years, when asked if this makes it harder to train, educators report the opposite, and that the increased number and diversity of cases enables more teaching opportunities.
Anaesthetic trainers report they do not have appropriate office facilities, with only 2 computer desks available for 19 consultants. This is felt to impact on the workforce well-being. There is a decommissioned theatre adjacent to the small consultant office, which has been identified as a usable space to extend into (RC4).
5. Delivering curricula and assessments
Most trainees report they can achieve their curriculum and assessment requirements, though some areas report there is little scheduled teaching. Anaesthetic trainees report they can meet their stage 3 training needs, and that access to high-risk anaesthesia clinics are enabled. Trainees report there has been an improvement in the availability of Airway equipment in A&E and this is now good with emergency grab bags available and restocked after use.
Paediatric trainees report they have regular meetings with their educational supervisors, and that senior support is available. They may miss teaching due to clinical pressures but report they get time off to attend regional teaching and that teaching is scheduled into the rota.
Surgery trainees also report they are well supported by their educational supervisors and can access training/teaching, but that weekends can be a struggle, as well as the on-call post-take, and that, at these times. they may miss elective surgery opportunities, but otherwise this is not an issue. Weekend pressures were not felt to be an issue for trauma and orthopaedic trainees.
Internal Medicine trainees report service pressures curtail access to clinics and regional teaching, and they do not have time to go to clinics and are required to come in on days off in order to achieve clinic requirements (RQ10). This was in contrast to the perception of trainers who felt that trainees could and did access clinics.
Acute Medicine foundation/GP trainers reported trainees can achieve requirements but noted there are sometimes difficulties, and trainees are sometimes overwhelmed. They report there is a fast pace in Acute Medicine which sometimes limits the support that can be provided (RQ10).
Foundation and ST1 Emergency medicine trainees report they rely on night shifts to complete assessments with the help of registrars, but higher ST trainees are challenged to complete assessments during shifts (RQ10). There has been consultant scheduled availability for assessments three times a week, but the rota is not published in advance and trainees are unable to plan for these. Emergency Medicine trainers were reported to be aware of the problem, and noted trainees need to be proactive to achieve requirements. The trainers mentioned they have recently shared their above work schedule with trainees.
Emergency Medicine trainees report some educators work to involve trainees in more roles and enable them to shadow consultants. Shadowing was reported to support trainees’ understanding of how decisions are made and why and supports trainees to share their perspectives (supports two-way understanding).
6. Developing a sustainable workforce
Anaesthetic, Paediatric and Surgery trainees would recommend PAHT as a training site due to the support provided by educational supervisors and other colleagues, and a perception that the culture of the trust is friendly and supportive.
Medicine trainees predominantly did not recommend training or want to pursue a career at the trust due to the perception they are unsupported, the feeling of being overwhelmed and the perception that they do not receive adequate training opportunities (RQ10).
Areas that are working well
| Description | Reference domain and standards |
|---|---|
| Trust wide – There is good engagement with NHS England WT&E Education Quality processes, and all meetings were well organised and well attended. | 1.1, 2.1, 2.3, 2.4, 2.7 |
| Trust wide – Many trainees and trainers noted a positive shift in the culture of the Trust. | 1.1, 1.2, 1.3, 1.5 |
| Trust wide – Trainers from all areas feel supported by the trust education team, the Director of Medical Education (DME) and Medical Director (MD). Educational governance processes across the trust are reported to be known and well embedded. | 1.1, 2.1, 2.4, 4.1, 4.3 |
| Trust wide – The new educational centre was praised as a useful resource to the trust and trainers. | 1.11, 2.5 |
| Trust wide – All trainees were aware of Datix and Exception reporting processes and reported these are covered in induction. | 1.4, 1.6, 1.7 |
| Trust wide – Trainees and trainers across programmes report there are good learning opportunities available at the trust. | 1.1, |
| Trust wide – Interprofessional relationships were felt to be helpful, with support from nurses, midwives and allied health professionals praised by trainees across programmes. | 1.3, 1.12, 3.8 |
| Trust wide – Most educators reported they have time in their job plans for educational supervision and are renumerated appropriately for this. | 4.2, 4.7 |
| Anaesthetic trainees report they can meet their stage 3 training needs, and that access to high-risk anaesthesia clinics are enabled. | 1.1, 3.7, 5.1, 5.3, 5.6 |
| Paediatric trainees report they have regular meetings with their educational supervisors, and that senior support is available. They may miss teaching due to clinical pressures but report they get time off to attend regional teaching and that teaching is scheduled into the rota. | 1.1, 3.6. 3.7 |
| Surgery trainees report they are well supported by their educational supervisors and can access training/teaching. | 1.1,3.6, |
| Emergency Medicine trainees report some educators work to involve trainees in more roles and enable them to shadow consultants. Shadowing was reported to support trainees’ understanding of how decisions are made and why and supports trainees to share their perspectives (supports two-way understanding). | 1.1, 3.8, 3.10 |
| Anaesthetics, Paediatrics and Surgery trainees were positive about their departments and the culture at the trust. These groups report they are well supported, receive training, and can achieve curriculum requirements and would recommend PAHT as a training site. | 1.1, 1.3, 1.4, 3.5 |
Good practice
| Description | Reference domain and standards |
|---|---|
| Trust wide – Trainers reported the DME is very good at sharing information and a WhatsApp group is utilised to promote education training opportunities. | 1.1, 2.1, 2.5, 4.3, 4.5, 4.6 |
| Trust wide / Emergency Medicine – The Medical Director has set up a new consultant development course which supports consultants across departments getting to know each other and in turn supports better professional relationships and an improved ability to support trainees in working across departments. | 1.12, |
| Trust wide – The trust MD, DME, non-executive director and Guardian of Safe Working (GOSW) delivered a presentation sharing their learnings following GMC Enhanced Monitoring which outlined a senior led, trust-wide approach to address issues, and work to enable a culture that fosters openness and transparency. | 1.1, 2.1, 2.3, 2.4, |
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action, timeline and evidence | Reference domain and standards |
|---|---|---|
| RQ1 –Supervision Medicine: Medicine trainees report they are frequently unable to access consultant support to review patients overnight who have deteriorated. | NHS England WT&E require assurance that a system is in place that ensures appropriate and timely consultant input. | Education Quality Framework Domain: 1.6, 3.5 |
| RQ2 – Referral Pathways Medicine: Medicine trainees reported there was lack of clarify over referral pathways to tertiary hospitals. | NHS England WT&E require assurance that a system is in place for timely onward referral of critically ill patients, including appropriate and timely consultant input. | Education Quality Framework Domain: 1.5, 1.6 |
| RQ3 – Safe staffing Medicine: Trainees from a number of specialties reported that the hospital was understaffed at night and felt this was regularly to unsafe levels. Acute medicine trainees reported they were unclear of what safe staffing levels were overnight particular following the reorganisation of the rota to include a twilight shift with an apparent reduction in overnight staffing and variable filling of rota gaps. Trainees felt with the twilight shift that the daytime staffing suffered, and often people who were rostered for twilight to support the front door (and reduce the number waiting to be seen by the night team) were often pulled to the wards instead due to understaffing. | NHS England WT&E requires assurance of safe staffing levels overnight, including assurance that rota gaps are being filled in a timely manner and more junior staff on overnight rotas have appropriate support. | Education Quality Framework Domain: 1.6, 3.5 |
| RQ4 – Safe Staffing Paediatrics: Paediatric trainees reported unsafe staffing levels as a consequence of managing patients in split sites across the Trust when one of the trainees is very junior (F2). | NHS England WT&E requires assurance of safe staffing levels overnight, including assurance that rota gaps are being filled in a timely manner and junior staff on overnight rotas have appropriate support. | Education Quality Framework Domain: 1.6, 3.5 |
| RQ5 – Appropriate staffing to ensure trainee/patient safety Anaesthetics: Anaesthetic trainees and consultants reported the lack of automatically available (ie as part of the attending team) advanced airway support by an ODP, as an integral part of cardiac arrest team leading to safety concerns for patients. | NHS England WT&E requires assurance of appropriate airways support available to attend Resus and A&E calls with trainee Anaesthetics. | Education Quality Framework Domain: 1.6, 3.5 |
| RQ6 – Safe staffing Anaesthetics: Anaesthetic staff also reported the lack of fourth tier junior cover at night resulted in safety concerns, particularly when trainees on the lower tiers are very junior. The trust provided an update and clarified the anaesthetics department recorded two Datix reports relating to staffing in the last 6 months, and will continue to monitor this and encourage colleagues to Datix report to further evidence these concerns. | NHS England WT&E requires assurance of safe staffing levels overnight, including assurance that rota gaps are being filled in a timely manner and junior staff on overnight rotas have appropriate support, particularly when very junior/inexperienced. | Education Quality Framework Domain: 1.6, 3.5. |
| Progress on immediate actions | Required action | Reference domain and standards |
|---|---|---|
| RQ1 –Supervision Medicine: The trust outlined that with immediate effect (as of 8.10.24) it has been agreed that the medical consultant responsible for the oversight of medical patients overnight (known as the Physician of the Day (POD)) will contact the on-call registrar by phone after handover has been completed. This will ensure that the registrar knows who and how to contact overnight when consultant support is required. This has been described to the co-chair of the RDC who is satisfied with its process. | NHS England WT&E requests the trust seek further feedback from Medicine trainees in 8 weeks (by 30 November 2024) regarding their perspectives on the escalation route and ability to access senior support. Summary of feedback will be requested as evidence towards sustained improvement in future improvement plan submissions. This item is likely to stay open and be a requirement in subsequent submissions until such time as we are assured there is a sustained change in the service. | Education Quality Framework Domain: 1.6, 3.5 |
| RQ2 – Referral Pathways Medicine: The trust identified the 4 clinical pathways that cause the most concern to residents and have reiterated the trust guidance. These have been shared with residents and PODs, published on the trust intranet and added to the Doctors toolkit (as document produced by resident doctors to support with pathways and processes at PAH). The trust also reiterated the importance of contacting the POD overnight if unsure about any referral pathway or have any concerns about the response from tertiary colleagues. | NHS England WT&E requests the trust seek further feedback from Medicine trainees in 8 weeks (by 30 November 2024) regarding their perspectives on referral pathways and the ability to access consultant support if unsure about referral pathways. Summary of feedback will be requested as evidence towards sustained improvement in future improvement plan submissions. This item is likely to stay open and be a requirement in subsequent submissions until such time as we are assured there is a sustained change in the service. | Education Quality Framework Domain: 1.5, 1.6 |
| RQ3 – Safe staffing Medicine: The trust compared staffing of PAHT medical wards and take with the HWE ICS to provide them with reassurance that medical staffing overnight is in line with similar acute trusts (provided evidence) and shared findings with resident doctors as well as clarifying minimum staffing levels with them. In this communication it was clarified that the introduction of the Twilight shifts was done in response to suggestions of last year’s resident doctors and has not impacted the number of doctors on shift overnight. The feedback received regarding twilight shift has been universally positive, acknowledging that it supports more of the day/evening work being done in real time rather than being left for the night team. | NHS England WT&E requests the trust seek further feedback from Medicine trainees in 8 weeks (by 30 November 2024) on their perception of staffing levels and overnight support. Summary of feedback will be requested as evidence towards sustained improvement in future improvement plan submissions. Evidence submitted should clearly demonstrate that all shifts (twilight and overnight) are filled and highlight and quantify the occasions on which they were not filled. This item is likely to stay open and be a requirement in subsequent submissions until such time as we are assured there is a sustained change in the service. | Education Quality Framework Domain: 1.6, 3.5 |
| RQ4 – Safe Staffing Paediatrics: The trust clarified that PAHT is not a split site geographically. There are 4 discrete sites where paediatric patients could reside: Paediatric Emergency (PED), Dolphin ward, NICU, and labour or postnatal ward. These areas are separate from each other but within the same building. There is a staggered staffing model which involves shifts covering all areas. From 20:30-9:00 there are 3 resident night staff, one SpR level in paediatrics and 2 SHO level who will have worked at least a year following graduation. Some of this staff will be new to paediatrics. The 2 SHO grades are for NICU and Dolphin/PED with the registrar cross covering both areas. The on-call consultant is resident until 22:00 and accessible by phone after this time. In addition to these staff there is an additional paediatric consultant covering PED until 22:00 (Mon – Thurs) and a twilight registrar covering PED until 23:00. The day team are onsite from 08:30. No patient safety issues have been raised via usual escalation processes regarding night staffing, but as an immediate action to perceived lack of support trainee feedback sessions have been scheduled with engagement from FTSUGs. Residents are reminded of escalation policy at induction. Escalation policy has been formalised and circulated amongst all grades. | NHS England WT&E requests the trust to remind trainees (especially FY and GP trainees) of escalation routes and support available as trainees perceive the situation is unsafe. NHS England WT&E suggests, that although this is not a split site, most departments of this size would have separate cover for Paediatrics and Neonates, we recognise that this may not be possible with the current establishment but suggest this be worked towards. | Education Quality Framework Domain: 1.6, 3.5 |
| RQ5 – Appropriate staffing to ensure trainee/patient safety Anaesthetics: The requirement to provide an ODP service to support Anaesthetics at cardiac arrests will be costed. Estimates are that five additional WTE ODPs would be required to ensure this service is provided. PAHT will look at costings to put together a business case (likely in a month’s time). Education Quality Framework Domain: 1.6, 3.5 | NHS England WT&E requests an update on the business case within the next improvement plan submission. Please include any safety incidents that result from the lack of an ODP on the cardiac arrest team as part of the next submission. | Education Quality Framework Domain: 1.6, 3.5 |
| RQ6 – Safe staffing Anaesthetics: PAHT confirmed as of 12.10.24 there were not enough trust appointed or middle grade Anaesthetists or SAS doctors to augment the current rota to 4 tiers. The RCT will work with resident doctor reps to establish and understand the frequency of when there were not enough anaesthetists to support emergency activity to provide context and correlate with reported incidents. The divisional director will meet with lead anaesthetists to identify the number of appointments necessary to expand the service to accommodate an additional tier. This is likely to be 6-8 doctors depending on seniority, with the cost to the organisation to be calculated. The trust anticipates 6 – 8 weeks before business cases are formally submitted. | NHS England WT&E requests an update on progress towards business cases within the next improvement plan submission. | Education Quality Framework Domain: 1.6, 3.5 |
Mandatory requirements
| Required action | Required action | Reference domain and standards |
| RQ7 Culture/Sexual safety Medicine, Emergency Medicine, and Surgery: Female trainees in Medicine, Emergency Medicine and Surgery reported they had experienced sexist behaviours (being challenged and/or excluded), with issues in surgery escalated and the situation supported and dealt with by the department. In the Emergency Department, trainees felt there were issues with preferential treatment more than sexism. There were mixed feelings amongst trainees regarding experiences of sexism and also favouritism not based on sex and/or race in Emergency Medicine. | The trust must ensure that the expected values and professional practice that trainees experience align with professional, regulatory, and NHS values. NHS England WT&E recognise that work is already in place within the trust to support sexual safety and promote mechanisms for trainees to escalate concerns relating to this and are supportive of the approach and welcome further updates on progress. We recognise that there may be an increase in reports of this nature as women feel more enabled to speak up. | Education Quality Framework Domain: 1.2, 1.3,1.8, 3.2, 3.3 |
| RQ8 Escalation of Concerns and Exception Reporting Medicine: Many Foundation trainees had not ever raised Datix or were choosing not to raise Datix due to the time it takes to complete them and the lack of belief that anything would be done. Higher Medicine trainees feel they raise the same issues repeatedly with no progress made. Some Medicine (Acute) trainees feel exception reporting is discouraged, though they are aware of the process and feel this is well covered in induction. They indicate seniors/consultants feel exception reporting is a negative reflection on themselves and trainees are reluctant to submit as it will get back to them, and there is reluctance to submit without explicit approval. Trainees stay late as they do not perceive it is safe to leave on time (safe for patients). | NHS England WT&E requires the trust to review escalation of concerns and exception reporting processes and ensure learners are enabled and supported to do so when required. The trust must ensure any escalations are fed back and trainee(s)/trainer(s) are included in the feedback loop. This item is likely to stay open and be a requirement in subsequent submissions until such time as we are assured there is a sustained change in practice and culture. | Education Quality Framework Domain: 1.1, 1.4, 1.5, 1.7 |
| RQ9 Induction Medicine: Medicine trainees reported induction was insufficient with no input from some specialties, and no GIM on-call induction. Some trainees did not receive appropriate logins and access to systems before starting shifts. | NHS England WT&E require assurance that: – trainees receive appropriate inductions into their placement areas with input from all subspecialties, and suggest the programme elicit trainee feedback and input for future induction sessions. – all trainees are allocated logins and access to IT systems before commencing in post. | Education Quality Framework Domain: 3.9 |
| RQ10 Access to teaching/training and ability to complete assessments Medicine and Emergency Medicine: Medicine trainees report service pressures curtail access to clinics and regional teaching, and they do not have time to go to clinics and are required to come in on days off in order to achieve clinic requirements. Many medicine trainees would not recommend the trust for training as they feel they are unsupported and do not receive adequate training opportunities. Foundation and ST1 Emergency medicine trainees report they rely on night shifts to complete assessments with the help of registrars, but higher ST trainees are challenged to complete assessments during shifts. There has been consultant scheduled availability for assessments three times a week, but the rota is not published in advance and trainees are unable to plan for these. | NHS England WT&E require assurance that: – Rotas are safely populated and learning opportunities are not impacted by rota gaps. – timetables, rotas, and workload enable learners to attend education sessions needed to meet their curriculum requirements during their contracted hours, including the EDT for EM trainees. – The rota for scheduled consultant availability to undertake assessments is made available well in advance. | Education Quality Framework Domain: 1.1, 3.6, 3.7 |
Recommendations
| Recommendation | Related education quality framework domain(s) and standard(s) |
|---|---|
| RC1 Interdepartmental working – internal professional standards procedure To ensure improved interdepartmental working across Surgery and Emergency Medicine: – NHS England WT&E recommend that the trust closely monitor the recently modified internal professional standards procedure to ensure strategies are effective. | Education Quality Framework Domain: 1.3 |
| RC2 Equity of training opportunities Emergency Medicine trainees perceived there was inequity in training opportunities across training grades. Trainees suggested the perceived inequalities could be addressed with a shift rota allocating doctors of different grades to the different areas (e.g. resus, majors, etc) rather than just for Paediatric ED. – NHS England WT&E recommend the trust work with trainees to enact an ED shift rota as suggested by trainees. | Education Quality Framework Domain: 1.3, 1.13, 3.2 |
| RC3 Standard of care Trainees report they do not trust the care provided by some locum consultants as they use nonstandard care plans which they felt contradicted NHS standard guidelines. · NHS England WT&E recommend the trust ensure all locum consultants are acting in line with standards as defined by the relevant regulator and/or professional body and are utilising NHS standard guidelines. | Education Quality Framework Domain: 1.4, 1.5 |
| RC4 Educator study leave Most trainers report they can access educator study leave and are able to use professional leave to support ARCPs. However, surgery and anaesthetics trainers report they were not given time off to support exams · NHS England WT&E recommends the Surgery Division review the allocation of study/professional leave to educators in order to enable them to support exams as required. | Education Quality Framework Domain: 4.2, |
| RC5 Facilities Anaesthetic trainers report they do not have appropriate office facilities, with only 2 computer desks available for 19 consultants. This is felt to impact on the workforce well-being. · NHS England WT&E recommend the trust supporting the Anaesthetic workforce with an adequate and usable office space to undertake rest breaks and deliver educational activities. | Education Quality Framework Domain: 1.11 |
Report approval
Report completed by: Marjorie Casey, Education Quality Manager
Review lead: Dr Rowan Burnstein, Deputy Postgraduate Dean
Date approved by review lead: 30 October 2024
NHS England authorised signature: Prof Bill Irish, Regional Multi-professional Dean/Regional Postgraduate Dean
Date authorised: 30 October 2024
Final report submitted to organisation: 2 December 2024