Executive summary

NHS England’s Education Quality Team conducted this review to anaesthetics and core anaesthetics at Barnet Hospital due to significant deterioration in the 2024 results within the General Medical Council’s National Training Survey (GMC NTS). The panel met with the Trust’s education and managerial leads, previous and current resident doctors training within anaesthetics and core anaesthetics and supervisors for the programmes.

The panel were pleased to hear that the department had appropriately actioned concerns raised within the GMC NTS 2024 results and that the Trust had demonstrated a commitment to improve training for anaesthetics resident doctors. However, the panel felt that there were still some improvements required.

Areas for improvement:

• rota arrangements and the consultant step-down / escalation policy required improvement
• ensuring departmental inductions are undertaken closer to when resident doctors work within the intensive care unit and/or on a different hospital site
• departmental teaching required improvements to the structure of the programme and greater collaboration for delivering this between the consultants and resident doctors
• the culture of the department required further improvement in addition to improving knowledge of the escalation process

The panel assigned a provisional Intensive Support Framework (ISF) rating of 2 for both the anaesthetics and core anaesthetics programmes. NHS England’s Education Quality Team will monitor the responses to the mandatory requirements detailed in this report during the quarterly Quality Management Portal (QMP) action cycle. 

Review overview

Background to the review

NHS England – London’s Education Quality team conducted an urgent risk review (Learner and Educator Review) of anaesthetics and core anaesthetics at Barnet Hospital due to a significant deterioration in the GMC NTS 2024 results.

Under post specialty by site for anaesthetics training, the results generated the following outliers:

• Fifteen red outliers: Overall Satisfaction, Clinical Supervision, Clinical Supervision out of hours, Reporting Systems, Work Load, Teamwork, Handover, Supportive Environment, Induction, Adequate Experience, Educational Governance, Feedback, Local Teaching, Rota Design, Facilities
• Two pink outliers: Educational Supervision, Study Leave

Under programme group by site for core anaesthetics training, the results generated the following outliers:

• Thirteen red outliers: Overall Satisfaction, Clinical Supervision, Clinical Supervision out of hours, Reporting Systems, Work Load, Teamwork, Handover, Supportive Environment, Adequate Experience, Educational Governance, Local Teaching, Regional Teaching, Rota Design
• Four pink outliers: Induction, Educational Supervision, Study Leave, Facilities

This urgent risk review sought to explore the reasoning behind the deterioration of the results, and aimed to support the Trust to improve the experience of doctors in postgraduate training within anaesthetics and core anaesthetics training.

Who we met with

Learners:

• Sixteen resident doctors training in core anaesthetics (current and previous cohort)
• Seven resident doctors training in anaesthetics (current and previous cohort)

Educators:

• Ten clinical supervisors and educational supervisors

Education team:

• Two Co-Directors of Medical Education (Barnet Hospital)
• Head of Postgraduate Medical Education
• Medical Education Manager
• Two College Tutors
• Medical Director (Barnet Hospital)
• Clinical Director
• Chief Executive (Barnet Hospital)
• Guardian of Safe Working Hours
• Divisional Operations Director for Surgery and Associated Specialties
• Divisional Director for Surgery and Associated Specialties
• Service Manager for Anaesthetics and Intensive Care Unit

Review panel:

• Education Quality Review Lead, Dr Vivienne Curtis, System Dean – North Central London, NHS England
• Specialty Expert, Dr Aasifa Tredray, Head of the London School of Anaesthesia, NHS England
• Specialty Expert, Dr Adrienne Stewart, Deputy Head of School of Anaesthesia, NHS England Role
• Learner Representative, Dr Rana Mallah, Lead Resident Doctor Representative, London School of Anaesthesia
• Lay Representative, Saira Tamboo
• Education Quality Coordinator, Nicole Lallaway, NHS England.   

Review findings

Anaesthetics department and action plan

The placement provider presented to the NHS England panel at the beginning of the review with a summary of the anaesthetics department and actions that had been taken to make improvements to anaesthetics training. The panel heard that anaesthetics training took place in both Barnet Hospital and Chase Farm Hospital. The panel heard that the department had 46 consultants and specialists and had recruited an additional two consultants due to join the department in December 2024. There were 32 NHS England funded resident doctors within anaesthetics and core anaesthetics, including six novices, 17 stage one resident doctors, eight stage two resident doctors and one intensive care medicine (ICM) resident doctor. The department did not have any stage three resident doctors in training. In addition, the department had nine locally employed doctors (LED), five foundation resident doctors, one advanced critical care practitioner (ACCP) and two student anaesthetic associates (AA). The panel heard that the department had five tiers of rotas (with an additional 6^th tier for novice resident doctors who don’t contribute to overnight work). It was reported that there were four slot gaps on the rotas and that there were additional gaps produced by five resident doctors working less than full time. Rota gaps were sought to be filled as a locum shift by current and previous resident doctors, and on occasions when there was short-term sickness absence, these were advertised as escalated rates.

The placement provider worked on an internal action plan to make some improvements to anaesthetics training. The panel heard that the rota was redesigned in August 2024 to reduce hours worked during the week, the removal of 12-hour shifts and weekly role change for the critical care anaesthetics trainee (CCAT) resident doctor rotating between providing cover for the labour was and the general theatres / intensive care unit (ICU). In addition, the escalation plan / consultant step-down policy was reviewed in September 2024. Resident doctor-led solo lists were changed to enable doctors to ‘opt-in’ rather than being rostered, and if last-minute sickness left a list without a consultant, resident doctors were not asked to be responsible for the lists as a solo mentored list. The panel heard that the department sought to improve departmental culture by holding Local Faculty Group (LFG) meetings monthly and enabling more feedback provided by resident doctors, and an anonymous online feedback form was developed by the college tutors as another means for providing feedback. The panel also heard that the Clinical Director had formally briefing the department on negative feedback received with examples from resident doctors, and the College Tutors were proactively offering support to consultants.

It was therefore clear to the panel that the Trust and the anaesthetics department was proactive in its response to the General Medical Council’s National Training Survey (GMC NTS) 2024 results, and it was felt that there was a demonstrable commitment within the faculty to making improvements to anaesthetics training. Resident doctors also reported that generally the department was felt to be more receptive to making changes, and that any issues raised via the LFG meetings were being heard and actioned with greater frequency. The college tutor was specifically commended by the resident doctors as having a positive impact on anaesthetics training.

Rota and staffing levels

The review panel heard that there were separate resident doctors covering the ICU North, ICU South, Labour Ward and Theatres in Barnet Hospital, and that after 18:00, there was an additional CCAT to provide support. However, whilst it was clear that work had been done to try to improve the rotas for resident doctors, there were still some concerns raised about rota coverage and appropriate levels of cover on the rota out of hours. In particular, the panel heard that the workload was high and perceived to be unsafe for the resident doctor working in ICU North, who was responsible for an 18-bed ICU whilst also doing outreach, including resuscitation and referrals. Resident doctors also felt they did not receive much support from the ICU consultant during the daytime, despite working on-site and often working in the consultants’ office, and that the workload for the resident doctor on ICU North was unsustainable.

The panel heard that four resident doctors on a shift was deemed to fulfil safe staffing levels, and that three resident doctors was the minimum acceptable level of staffing on any given shift. However, resident doctors training in anaesthetics and core anaesthetics felt strongly that out of hours cover was unsafe when there were fewer than five resident doctors working on a shift, and that safe levels was particularly dependent on the skill-mix and experience of resident doctors.  It was noted that the majority of resident doctors working within anaesthetics were working at a more junior level, with the highest level of training being CT4. The panel heard that there were some shifts with known, regular rota gaps, and resident doctors estimated that each week shifts were down to four people, and they were down to three people on a shift approximately once a month. When rota gaps were known in advance, the department sought to fill rota gaps with locum doctors where possible, but it was understandably difficult to fill late notice rota gaps due to sickness absence. Despite this, the review panel were pleased to hear that there were no issues regarding resident doctors staying late to complete jobs. It was reported that there was an escalation policy reviewed by the department in September 2024 which identified what to do when there were out of hours resident doctor rota gaps including consultants stepping down to fill gaps. However, the review panel felt that the department would benefit from establishing improvements to rota arrangements and conducting additional work on the escalation policy, and that this should be approached with greater collaboration between the resident doctors and consultants in anaesthetics.

The panel heard from Clinical Supervisors (CS’) and Educational Supervisors (ES’) that the work could be stressful due to rota gaps at resident doctor level, and that it could be difficult for consultants to step-down at short notice. It was also felt that there was a lot of pressure on consultants for service delivery, with theatre lists reportedly booked to 110-120% capacity which may have had an adverse effect on training. It was reported that there were instances where they were unable to provide epidurals or delays to providing epidurals due to busyness on the wards, especially if there was no CCAT doctor to provide additional support. The panel also heard that there was an unofficial policy whereby consultants who work until 12:00am or for half of the night were not required to work the next day as this was deemed to be unsafe. CS’ and ES’ were grateful for this as a way to manage workload.

Induction, teaching and adequate experience

The panel acknowledged that improvements had been made to the induction process since the previous quality review in October 2022, however it was felt that further improvements were required. Resident doctors reported that induction could have been timelier, as there could be a six-month gap between the initial departmental induction at the start of their placement and when they began working at a different hospital site or began working within the ICU. Resident doctors felt that by that point they often forgot anything mentioned during induction about working in the ICU. There was also a mention of making resident doctors feel welcomed by the department and valued in their role during induction as well.

The panel heard that there were 14 afternoons of formal departmental teaching scheduled for resident doctors, which included anaesthetics, ICU and a Fellowship of the Royal College of Anaesthetists (FRCA) refresh. In addition, the panel heard that the monthly Mortality and Morbidity (M&M) meetings were hybrid to enable attendance across multiple hospital sites, and that there was a slot during this meeting for formal ICU teaching. The panel felt that the department had facilitated resident doctor attendance to teaching. However, it was not clear that the anaesthetics sessions followed a structured curricular programme, with resident doctors noting they wanted more consultant engagement in the teaching sessions. It was reported that local teaching for anaesthetics had a timetabled session which was conducted between a rotation of consultants and resident doctors, and that each pairing would be expected to put together a plan and topic for each session. Resident doctors reported that this was variable and that often teaching sessions were planned and led by the resident doctors.

Resident doctors in anaesthetics reported that they were concerned about getting adequate experience within paediatrics to fulfil their required curriculum requirements. The panel heard that there was not adequate access to paediatric anaesthesia numbers at Barnet Hospital, and that the Training Programme Director (TPD) informed resident doctors that they would be required to find a paediatric slot themselves during their training.

Novice resident doctors reported that they had a positive experience of training within Barnet Hospital, and that they felt well supported by the department. It was felt that there was adequate capacity to train resident doctors at this level, and that they were not asked to conduct any work outside of the scope of their competency.

Culture

The panel recognised that the anaesthetics department and the wider Trust had done lots of work to improve the departmental culture, however there were still some instances of resident doctors having negative experiences. The panel heard that there was some reluctance from a small number of consultants to allow resident doctors to use the consultants’ office as a space to sleep and rest during a shift, however it was reported that this issue was resolved quickly. It was also raised that there were some instances of resident doctors being belittled by consultants in front of patients, and there was mention of some instances of racist comments made by a small number of consultants. This was escalated by resident doctors within the Trust; however, it was reported that it took a long period of time to act upon and resolve these issues. Resident doctors were also not aware of who the Freedom to Speak Up (FSTU) Guardian was and were unsure of the processes for raising concerns. The panel also had the impression that concerns raised took a long time to be investigated and feedback was not delivered to resident doctors in a timely manner. In addition, the panel heard from CS’ and ES’ that active bystander training was not proactively taken up, and that for the small number of supervisors who did access this, was not felt to be a substantial session.

Resident doctors reported that they experienced some issues with access to parking at Barnet Hospital, and it was felt that there was inequitable access for resident doctors compared to consultants, particularly when working out of hours and on the weekends.

Educators

CS’ and ES’ felt that the number of resident doctors they were responsible for was appropriate with a range of two to four resident doctors allocated to each supervisor. The panel heard that CS’ and ES’ were being appropriately renumerated for their work with 0.25 PA time allocated to supervisors for each resident doctor, in line with NHS England guidelines for education and training. CS’ and ES’ also reported that they were able to join Annual Review of Competency Panels (ARCP) as a development opportunity, however they had experienced some difficulty in claiming the time as study leave.

Anaesthetics resident doctors reported that sometimes their mentor was not aware they were supposed to be mentoring them when doing a solo mentored theatre list, and that they often had to present themselves to their mentor to make them aware.

The panel heard that the consultant body was more actively engaged in asking resident doctors what they wanted to learn, and that more effort was put into providing access to appropriate theatre lists for anaesthetics resident doctors. All resident doctors in attendance at the review had positive experiences with their educational supervisors, and when asked if they would recommend their friends and family to Barnet Hospital for treatment, resident doctors reported they were generally happy in terms of access to elective care, however they had some reservations about care out of hours and emergency care if there was a need for ICU admission.

The panel highlighted that when the placement provider is working through service reconfiguration during the merger with North Middlesex University Hospital NHS Trust, there needed to be consideration for the impact on the faculty and training, particularly consideration for a balance between service provision and training opportunities for resident doctors.

Areas that are working well

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Nicole Lallaway, Education Quality Coordinator – NHS England
Review lead: Dr Vivienne Curtis, System Dean – North Central London – NHS England
Date approved by review lead: 21 November 2024

NHS England authorised signature: Dr Elizabeth Carty, Interim Local Postgraduate Dean – NHS England
Date authorised: 21 November 2024

Final report submitted to organisation: 21 November 2024

Publication reference: PRN01548