Executive summary
On November 21 and 5 December 2024 virtual engagement meetings were held with the Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust (QEHKL) resident doctors and trainers in surgery and the surgical specialties to review the impact of concerns identified in the 2024 General Medical Council (GMC) National Training Survey and supported by internal programme intelligence.
This report has been written in a manner to preserve the anonymity of residents and includes commendations for areas of good practice as well as educational requirements that need to be addressed.
The meetings demonstrated areas that were working well and good practice which included:
- Trainers were aware of some resident doctors’ concerns and took proactive steps to review resident feedback (including GMC NTS) with a view to improve the quality of the learning environment.
- Foundation Trauma & Orthopaedic (T&O) residents felt positively about weekly teaching, particularly the non-core aspect of orthopaedics training, and felt the department put great effort into this training and took steps to ensure middle grades and consultants positively contributed to teaching.
- Educational supervisors were remunerated appropriately and had a weekly dedicated 1-hour time slot reflected in their job plans.
- Foundation Training Programme Directors were described as kind and approachable. The postgraduate administration team, rota staff, and managers were generally supportive and responsive.
- We heard that higher residents felt valued by the department (especially in T&O).
The meeting feedback also demonstrated challenges in the clinical learning environment which need to be addressed including:
- Resident and patient safety concerns were reported involving foundation resident supervision, resident doctors working outside their scope of competence and confidence, the impact of the list system on patients and training, and inadequate handover processes.
- Exception reporting was not felt to be encouraged, with working out of hours normalised.
- Cultural concerns were reported, including examples of bullying and undermining and misogyny.
- Rotas did not adequately support access to planned education sessions, study/annual leave, and appropriate rest time between shifts.
- Portfolio sign off for Foundation residents was reported to be variable.
Review overview
Background to the review
The review meetings were implemented following concerns regarding the clinical learning environment highlighted via the 2024 GMC NTS priority list and outcomes for foundation surgery and trauma and orthopaedic surgery. The review meeting has been conducted in accordance with the NHS England Education Quality Framework Domains and Standards for Quality Reviews.
Who we met with
Resident Doctors
- 11 Foundation resident doctors.
- 7 higher resident doctors and 1 SAS doctor.
Educators
- 8 trainers across general surgery and multiple surgical specialties.
Education team
- Medical Director
- Director of Medical Education
- Associate Directors of Education
- Group Medical Education Manager
- Director of People
- General Surgery Clinical Director
- Foundation Programme Directors
Review panel
- Ryan Collins, Education Quality Intelligence Analyst, Education Quality Review Lead
- Ms Claire Edwards, Head of School of Surgery, Specialty Expert
- Dr Helen Barker, Foundation School Director, Specialty Expert
- Agnes Donoughue, Education Quality Coordinator
Review findings
Learning environment and culture
Higher residents felt that consultants were keen to teach and generally supportive. We heard that higher residents felt valued by the department (especially in T&O) and that foundation T&O residents felt positively about weekly teaching, particularly the non-core aspect of orthopaedics training – it was felt the department put great effort into this training and took steps to ensure middle grades and consultants positively contributed to teaching. However, the rota did not always enable training to proceed as scheduled. Foundation Training Programme Directors were described as kind and approachable. The postgraduate administration team, rota staff, and managers were generally supportive and responsive.
Support from registrars and consultants, in contrast, was perceived to be variable. This was underpinned by behaviours and comments felt to be uncivil which would, occasionally, be perceived as bullying and undermining (RQ2).
All resident doctor groups that we met with had some concerns about education and training. Foundation residents had shared anxieties about quality of care and culture; higher residents perceived culture and quality of care more positively. Trainers were aware of some resident doctors’ concerns and took proactive steps to review resident feedback (including GMC NTS) with a view to improve the quality of the learning environment.
Some foundation residents frequently felt excluded from conversations when consultants would communicate in their native language, as opposed to English (RQ2). Behaviours experienced by foundation residents were sometimes perceived as misogynistic. For example, we heard that some staff spoke negatively about female staffs’ response to stress and that female staff would sometimes be ignored, with these behaviours felt to go unchallenged by the trust (RQ2).
Foundation residents cited some examples of strong supervision, however there were concerns about consultant accessibility on the ward after 5pm (RQ1). Multiple residents would welcome receiving consultant feedback in a more private and constructive manner. Some residents felt ‘scapegoated’ and not supported for decisions made when they were unable to access advice (RQ2).
We heard that foundation residents felt some consultants were unsupportive of education and training; this was partially attributed to service pressures and residents would welcome additional learning opportunities during on call ward rounds.
Resident doctor and patient safety
Foundation residents felt “unsafe” making medical decisions perceived to be outside their scope of practice in the absence of sufficient supervision. We heard from foundation residents that microbiology would only offer advice to clinicians of registrar grade or higher. On an occasion when the registrar was unavailable, they were unable to obtain support regarding antibiotic choice for a complex patient who was very unwell. We also heard reports of insufficient support for F2 orthopaedic residents on night shifts; the orthopaedic registrar was not consistently available, and the general surgery registrar was reportedly unable to support. This had led to them feeling pressured to accept referrals on occasion although they understood they were not authorised to do so. It was indicated that if registrars were not contactable, SHOs would be bleeped. SHOs felt they were authorised to clerk patients with neck of femur fractures but would be required to clerk patients outside their scope of practice at times of high service pressure. At times, foundation resident doctors were unclear on escalation pathways because some consultants indicated they could be escalated to for advice during shift whereas others indicated they could not be escalated to (RQ1).
There were also concerns about patient oversight – foundation residents cited an example in general surgery where a patient did not receive appropriate care for 2 weeks because they were not included on the MS Word patient list. Foundation residents felt that the list system was dysfunctional and that prepping three separate lists and tracking patients through a MS Word document (that could only be accessed by one person) consumed significant amounts of time.
We heard that there was no confidential space for handover meetings to occur; there were challenges finding a location for evening handovers and daytime handovers would often take place in the boardroom; resulting in a presentation screen being used to review x-ray outcomes as opposed to a screen designed for this purpose, which adversely impacted residents’ ability to interpret images (RQ1). Trainers also expressed a desire for improved handover facilities. Handover of patients between consultants was not always perceived as being clear with varying surgeon preferences and poor communication leading to confusion for the residents and delays in treatment progression for patients. Following the departure of a locum consultant residents felt that there was not a clear handover of consultant level responsibility or a clear plan for the cohort of patients who had been treated by the departing locum (RQ1).
Facilities
Facilities feedback was mixed. Foundation residents praised facilities, including the library, doctor’s mess, and food at the hub (including the daily free hot drink). Whereas higher residents cited a lack of a dedicated/confidential space for handover. We also heard from higher residents that some areas of the trust had limited functioning computers available (RC1). Trainers stated that senior management were aware of facilities and room booking challenges.
Educational governance and commitment to quality
The general consensus amongst foundation residents was that exception reporting was rarely utilised. We heard that some residents had been paid for additional hours worked whereas others had their hours approved but had not received payment (RQ3). One resident commented that additional hours had been approved but not paid by the department. Some residents had been discouraged from exception reporting (RQ3). Higher residents also had negative experiences of exception reporting when they were on the tier 1 rota, resulting in a reluctance to exception report and a normalisation of working out of hours without exception reporting (RQ3).
Developing and supporting learners
Residents had variable perceptions of induction quality; some residents were positive about the opportunity to shadow a consultant for a week; but the quality of shadowing was variable by consultant. Foundation residents were unaware of a trust or departmental induction handbook and would welcome this – especially for highlighting the systems they would need access to (RC2).
Higher residents had concerns about receiving sufficient rest between shifts and that the intensity of working overnight was heavily contributed to by on calls (RQ4).
Developing and supporting aupervisors
Educational supervisors were remunerated appropriately and had a weekly dedicated 1-hour time slot reflected in their job plans.
Delivering curricula and assessments
Portfolio sign off for Foundation residents was reported to be variable, with some supervisors very helpful and others unresponsive to emails; we heard some residents were awaiting PDP sign off (RQ5). This was felt to be compounded by the absence of training registrars and limited dedicated time with consultant supervisors, with start and end of placement meetings in place but a lack of touch points in between, and it was felt trainers were unclear on sign-off processes (RQ5). Foundation residents felt theatre access and formal departmental teaching was limited and higher residents had concerns about achieving the number of theatre cases required by their curriculum (RQ4).
Rota
Although Foundation residents felt that rota staff were kind, it was felt the rota had scope for improvement and rota colleagues could do more to address residents’ rota concerns. Higher residents, primarily in orthopaedics, cited challenges with rota enabled access to regional teaching as well as annual and study leave. They also felt that the rota was non-conducive to the achievement of educational objectives in terms of theatre and clinic access. We heard that rota gaps often went unfilled even when they were identified days in advance, resulting in rotas non-compliant with training standards (RQ4).
Areas that are working well
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
| Educational supervisors were remunerated appropriately and had a weekly dedicated 1-hour time slot reflected in their job plans. | Developing and Supporting Supervisors: 4.2 |
| Foundation Training Programme Directors were described as kind and approachable. The postgraduate administration team, rota staff, and managers were generally supportive and responsive | 1. Learning environment and culture: 1.3 |
| We heard that higher residents felt valued by the department (especially in T&O). | 1. Learning environment and culture: 1.3 |
Good practice
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
| Trainers were aware of some resident doctors’ concerns and took proactive steps to review resident feedback (including GMC NTS) with a view to improve the quality of the learning environment. | 1. Learning environment and culture: 1.1 |
| Foundation T&O residents felt positively about weekly teaching, particularly the non-core aspect of orthopaedics training. It was felt the department put great effort into this training and took steps to ensure middle grades and consultants positively contributed to teaching. | 1. Learning environment and culture: 1.1 |
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| Supervision, working within scope of practice, impact of list system on patients and training, handover Supervision and working within scope of confidence and competence Foundation residents felt “unsafe” making medical decisions perceived to be outside their scope of practice in the absence of sufficient supervision. We heard from foundation residents that microbiology would only offer advice to clinicians of registrar grade or higher. On an occasion when the registrar was unavailable, they were unable to obtain support regarding antibiotic choice for a complex patient who was very unwell with an infective skin condition. We also heard reports of insufficient support for F2 orthopaedic residents on night shifts; the orthopaedic registrar was not consistently available, and the general surgery registrar was reportedly unable to support. The F2 was pressured to accept a referral although they understood they were not authorised to do so; this caused stress for the resident. It was indicated that if registrars were not contactable, SHOs would be bleeped. SHOs felt they were authorised to clerk patients with neck of femur fractures but would be required to clerk patients outside their scope of practice at times of high service pressure. At times, foundation resident doctors were unclear on escalation pathways because some consultants indicated they could be escalated to for advice during shift whereas others indicated they could not be escalated to. Patient oversight / list system There were also concerns about patient oversight – foundation residents cited an example in general surgery where a patient did not receive appropriate care for 2 weeks because they were not included on the MS Word patient list. Foundation residents felt that the list system was dysfunctional and that prepping three separate lists and tracking patients through a MS Word document (that could only be accessed by one person) consumed significant amounts of time. Handover We heard that there was no confidential space for handover meetings to occur; there were challenges finding a location for evening handovers and daytime handovers would often take place in the boardroom, resulting in a presentation screen being used to review x-ray outcomes as opposed to a screen designed for this purpose, which adversely impacted residents’ ability to interpret images. Handover of patients between consultants was not always clear with varying surgeon preferences and poor communication leading to confusion for the residents and delays in treatment progression for patients. Following the departure of a locum consultant residents felt there was not a clear handover of consultant level responsibility or a clear plan for the cohort of patients who had been treated by the departing locum. Foundation residents cited some examples of strong supervision, however there were concerns about consultant accessibility on the ward after 5pm. | Further to the action plan implemented by the trust in response to these concerns, which was shared with NHS England WT&E December 5, 2024, NHS England WT&E requests the trust: Provide an update on actions taken following the trust’s review to sustain and embed availability of foundation resident access to registrar/consultant support. Patient oversight – specifically the MS word patient lists in General Surgery to provide assurance on patient list management. Provide an update on the Director of Estates’ efforts to identify suitable space for handovers for General Surgery. Progress update on handover processes with a focus on locum to substantive processes. | RQ1 1. Learning environment and culture: 1.5, 1.6 3. Developing and supporting learners: 3.4 |
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| Culture Support from registrars and consultants, was perceived to be variable. This was underpinned by behaviours and comments felt to be uncivil which could, be perceived as bullying and undermining. Some foundation residents felt excluded from conversations when consultants would communicate in their native language, as opposed to English. Behaviours experienced by foundation residents were sometimes perceived as misogynistic and these behaviours were felt to go unchallenged by the trust. Residents would welcome receiving consultant feedback in a more private and constructive manner. Some residents felt ‘scapegoated’ for decisions made when they were unable to access advice. | The trust to ensure that the expected values and professional practice that residents experience on placement align with professional, regulatory, and NHS values. NHS England WT&E requires assurance that the trust’s expectations regarding their commitment to quality of care has been clearly articulated to all staff. This is to encompass the need to challenge and address misogynistic behaviours. NHS England WT&E requires the trust to identify an appropriate individual to work with residents to gain a better understanding of what their experiences of bullying and undermining. NHS England WT&E requires assurance that the trust is taking steps to make the surgery department’s training environment conducive to NHS values, including: Staff receive appropriate training on how to support resident doctors. | RQ2 1. Learning environment and culture: 1.2, 1.3, 1.8 2. Educational governance and commitment to quality: 2.2 3. Developing and supporting learners: 3.8 |
| Exception reporting, including normalisation of working out of hours Foundation residents reported that exception reporting was rarely utilised. We heard that some residents had been paid for additional hours worked whereas others had their hours approved but had not received payment. Some residents had been discouraged from exception reporting. Higher residents also had negative experiences of exception reporting when they were on the tier 1 rota, resulting in a reluctance to exception report and a normalisation of working out of hours without exception reporting. | NHS England WT&E seeks assurance that: Resident doctors utilising exception reporting mechanisms feel that the processes are effective. Residents are enabled to exception report concerns about frequently working out of hours, including escalations to the Guardian of Safe Working. | RQ3 1. Learning environment and culture: 1.7 |
| RQ4 Rotas including access to planned education sessions, study/annual leave, and appropriate rest time between shifts Higher residents had concerns about receiving sufficient rest between shifts and that the intensity of working overnight heavily contributed to by on calls. Although Foundation residents felt that rota staff were kind, it was felt the rota had scope for improvement and rota colleagues could do more to address residents’ rota concerns. Higher residents, primarily in orthopaedics, cited challenges with rota enabled access to regional teaching as well as annual and study leave. They also felt that the rota was non-conducive to the achievement of educational objectives in terms of theatre and clinic access. We heard that rota gaps often went unfilled even when they were identified days in advance, resulting in rotas non-compliant with training standards. Foundation residents felt theatre access and formal departmental teaching was limited and higher residents had concerns about achieving the number of theatre cases required by their curriculum. | NHS England WT&E requires assurance that all resident doctors’ rotas and workloads enable residents to attend the planned education sessions and regional teaching by: Undertaking an audit to ensure that resident doctors receive appropriate rest time between shifts in line with legislative requirements and taking remedial action where required. Reviewing the mitigations in place to manage foreseeable absences. Ensuring clinic and theatre access is enabled by the rota and seeking resident feedback regarding residents’ confidence they will meet their curriculum requirements, taking remedial action on a specialty-by-specialty basis where required. Taking steps to ensure resident doctors are appropriately supported to attend regional teaching. | RQ4 5. Delivering Curricula and Assessments: 5.1 |
| E-portfolio sign off Portfolio sign off for Foundation residents was reported to be variable, with some supervisors very helpful and others unresponsive to emails; we heard some residents were awaiting PDP sign off. This was felt to be compounded by the absence of training registrar and limited dedicated time with consultant supervisors, with start and end of placement meetings in place but a lack of touch points in between – it was perceived that trainers were unclear on sign-off processes. | NHS England WT&E requires that the trust takes steps to ensure resident doctors are supported in evidencing their progress against curriculum requirements by: Ensuring trainers are appropriately supported to understand all necessary elements of E-portfolio sign off. Implementing actions to ensure E-portfolio sign-offs are provided in a timely manner and resident doctor feedback is collected on an ongoing basis to evidence the effectiveness of actions implemented. | RQ5 1. Learning environment and culture: 1.1 |
Recommendations
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
| To ensure the learning environment provides suitable IT for resident doctors: NHS England WT&E recommends that the trust review the availability of IT equipment with a view to improve resident doctor access. | RC1 1. Learning environment and culture: 1.11 |
| To improve resident doctors’ induction experience: NHS England WT&E recommends that the trust provide resident doctors with an induction handbook following trust and departmental inductions, this should signpost to systems resident doctors require access to. In the event this provision is in place and resident doctors were unaware, we recommend signposting resident doctors to this resource. | RC2 3. Developing and supporting learners: 3.9 |
Report approval
Report completed by: Ryan Collins, Education Quality Intelligence Analyst
Review lead: Tracy Wray, Lead for Education Quality
Date approved by review lead: 23 July 2025
NHS England authorised signature: Prof Bill Irish, Postgraduate and Multi-professional Dean
Date authorised: 24 July 2025
Final report submitted to organisation: 2 September 2025