Executive summary

This triggered review was prompted by a highly engaged training programme director, who brokered a direct conversation between the doctors in neurology training and key stakeholders in the deanery. We met with seven doctors at a range of grades in higher specialty neurology training and heard about their experiences at the trust.

We found two key issues on which most of the concerns were centred.

• A perceived hierarchical culture which was problematic in inhibiting doctors in training from raising concerns and undermined their confidence.
• A relatively new and evolving thrombectomy service, which has come to place a large degree of pressure on the doctors we spoke to.

The areas for improving – and hopefully restoring to previously excellent levels – the experience of doctors in higher specialty neurology training are therefore linked to these areas, and include considerations of culture and civility, and a review of the thrombectomy service.

Immediately following the conversation with the doctors in training, we met with and fed back to the medical director and medical education team. We learned that the majority of the issues we raised were known to the organisation and there were plans in place to resolve many of the concerns, including a review of the thrombectomy service.

We have detailed our review findings more clearly in the body of this report and outlined actions we expect the trust to take to resolve the issues. We will expect an action plan from the trust to meet these requirements and have no further plans to revisit the trust in the immediate future unless the action plan does not progress as planned.

Review overview

Background to the review

The Walton Centre has had a history of remarkably consistent positive results across the full range of training programmes in the GMC National Training Survey (NTS) in recent years, and we had no active concerns ahead of the present issues being raised.

In 2019, the neurology programme results had four positive statistical outliers, continuing a trend of between four and seven positive outliers for the programme every year of the survey going back to at least 2016.

The exception to the streak of good outcomes for doctors in training is in the neurology training programme in the aftermath of the COVID-19 pandemic. The 2020 survey is not comparable due to a change in survey during the pandemic, but it returned in its previous form in 2021 by which time there was only one positive outlier for the neurology programme and one potentially negative outlier. In 2022 there were no positive and no negative outliers; all results were in the interquartile range. In the 2023 results there were two negative outliers and four potential negative outliers and in the latest 2024 survey the neurology programme had eight negative outliers and four further potential outliers.

The worrying drop in scores in recent years had prompted the Neurology Training Programme Director (TPD) to seek support from the deanery, and we agreed at short notice to meet with the doctors in neurology training to hear their experience of the standards of education and the provision of training at the trust.

Who we met with

Learners

• 7 × doctors in higher specialty neurology training

The information and recommendations in this report are based on the meeting with learners.

Following this we invited members of the Medical Education Team, the Neurology Training Programme Director (whom the trust inform us is also temporarily acting as Trust Specialty Training Lead) and the Medical Director into the room for brief feedback from the panel.

Review panel

• Richard Hughes – Associate Dean (Education Quality Review Lead)
• Sameer Misra – Associate Dean
• Raj Parikh – Head of the School of Medicine
• Zander Zambas – Education Quality Manager
• Leanne Moore – Education Quality Coordinator

Review findings

This was a triggered review, initiated by concerns being raised within the trust and escalated to the deanery. As such, we allowed the doctors to lead the conversation and share their highest priorities and their most pressing concerns with us, and explored and expanded from there.

To open, the doctors shared with us a sense of building resentment linked to the gradual erosion of morale among staff. This was intended to mean low morale amongst the doctors in neurology training, but when asked to clarify there was some reflection that low morale may extend to some of the consultants – particularly the subset of consultants who are on the on-call rota – and also in related nursing and administration posts. This background made smaller issues more challenging to deal with, we were told.

The doctors in training identified the key reason underpinning this erosion of morale as the workplace culture. We were told of many examples to illustrate what was difficult about the department and the trust culturally, including several recent stories of doctors in training being brought to tears by unpleasant interactions with colleagues. They also identified numerous subtle reinforcing behaviours which served to maintain a strict hierarchy, for example resistance among some consultants to being on first name terms with the doctors in training, few opportunities for shared lunchtime as there is no staff dining area (except weekly clinical academic meetings), consultants delegating small administrative tasks – which may be as quick to do as to delegate – to doctors they had no relationship with or had never met. These subtle cultural differences were more clearly articulated by those who had experience of working in other units with a flatter hierarchy and had previously, for example, had lunch regularly with the team of educators.

We were also told about a history of cultural issues within the acute services of the trust. Some of the neurology doctors had been with the trust in previous years and remember during their induction being warned about the culture of interdepartmental relations. On reflection in recent years (i.e. the period of negative feedback for medical neurology) the doctors we spoke to said that challenging interactions with other acute departments were not the norm and relationships had improved.

Although a problematic culture of interpersonal and professional relationships was described between consultants in neurology and doctors in neurology training, the perception by doctors in training was that there was ‘a handful’ of exceptions to the rule. We were told of consultants who were very engaged in education and/or very approachable – most (not all) were newer consultants, most (not all) were on the on-call rota. The TPD was name checked at this point, appreciating his engagement and energy in “fighting to improve education” and “turning the tide of COVID changes”.

There was acknowledgement that structural factors prevented some staff groups from mixing. They estimated there were over 60 consultants and only around a dozen doctors in training – so they are “vastly outnumbered”. We subsequently had confirmation from the Neurology Divisional Director that there are 44 consultants, though it is clear that there is a perception of being more significantly outnumbered. With most of the consultants not on the on-call rota there is little interaction between those consultants and the doctors in training.

In additional to the profound impact of low morale resulting from this cultural hierarchy, we were concerned by several other aspects of what we heard about workplace culture.

• Doctors in training who had been active in raising concerns felt that they were subject to different treatment from others.
• Behaviour from several consultants (past and present) which was described as ‘obviously problematic’ seemed not to have been dealt with appropriately.
• Clinic supervision was said to be very variable, depending on the particular consultant on the day.
• Feedback to doctors in training was not consistently useful, timely, or appropriate; one doctor told us the only feedback they had received was through the summative Multiple Consultant Report, without any formative feedback stage.

The panel was aware of issues with the thrombectomy service, so opened a line of questioning into how the service worked and what the doctors thought about it. In describing a fairly standard thrombectomy referral, it was striking how much menial administration was expected of a doctor in higher specialty training – finding relevant people in the hospital, coordinating ambulances, opening case notes etc. As a 24-hour service, these thrombectomy referrals and the associated administration frequently disrupted overnight, non-resident on-call shifts. We were concerned that learning opportunities for quality improvement in the stroke pathway might be missed because the doctors in neurology training felt less able to feed back their observations of day-to-day challenges. This issue is known by the trust and we were subsequently told there has been significant investment in the pathway with changes being introduced, which they hope will come into effect in the near future.

The on-call rota for neurology doctors was not something the panel had come across before. While the doctors in training on the rota supported the shift pattern’s potential to provide for a more normal, planned life outside work when not on-call, the two weeks of on-call shifts seemed to us to be gruelling. We understood it to be 24-hour shifts on-call, half resident and half non-resident, every other day, with a shift on the alternate day. This led us to question the compliance of the rota, the safety of the doctors when driving with such accumulated fatigue, the availability of rest facilities and the overall wellbeing of the doctors during these on-call weeks. Although we did not elicit significant support for redesigning the rota, we were not assured that doctors were supported with adequate rest facilities or able to manage their safety and wellbeing while on-call.

The 24-hour thrombectomy service is seen as a relatively new service, which is rapidly expanding with more referrals, and is a service which is delivered primarily by interventional radiologists after referral from (often) a stroke consultant. The outsized impact that this service has on the rota, balance of training against service provision and the frequency with which the service puts doctors in neurology training in difficult positions underscores the need for a significant redesign of the service.

The doctors shared numerous ideas for improving the service which they were currently delivering and they were aware of a service redesign and recruitment of Advanced Nurse Practitioners for Stroke to bolster the service. However, they felt that they had been consulted, engaged with, or otherwise involved in the redesign less intensively than they might have been. The trust will miss out on their expertise and sensible and pragmatic suggestions if it does not ask for their input to this process.

To wrap up our session with the doctors in neurology training, we asked about overall satisfaction with the job, whether these doctors would consider taking up a consultant post at this trust, and whether they would recommend this as a training post and a place to work to one of their peers. The room was split on whether to recommend the post and whether they would take up a consultant post here. Clearly some doctors appreciated the interesting case mix and the learning opportunities. Those that would not recommend the post cited the overall culture, in particular the lack of confidence in governance and procedures that ensure concerns are followed up and things change.

Areas that are working well

• There is a strong, engaged and well-respected TPD for neurology who is seen by the doctors in training to be driving improvements in the service.
• Some challenges faced by the trust, the department and the doctors come from changes that were rapidly implemented during the COVID-19 pandemic. We heard that some educators had turned the trust around from COVID challenges.
• The trust has a track record of holding difficult conversations and overcoming some cultural challenges with its review programme of work around other acute areas of the trust.
• A taskforce was convened by the neurology clinical director based on feedback from the National Training Survey, made up of two senior members of the neurology department, a consultant from another speciality and four doctors in neurology training. The taskforce met three times during September-October 2024 to make recommendations, which were approved during a neurology away day in early November 2024.

Good practice

• The Wednesday Breakfast Club which provides a teaching opportunity for was well received and appreciated. The educators who organise and run this are to be commended.
• Doctors were highly satisfied with their exposure to clinics.

Areas for improvement

Mandatory requirements

Recommendations

• Build in review of referral and case management system for thrombectomy service from Aintree as part of service review.

Report approval

Report completed by: Zander Zambas, Quality Support Manager
Review lead: Richard Hughes, Associate Postgraduate Dean
Date approved by review lead: 10 December 2024

NHS England authorised signature: Raghu Paranthaman
Date authorised: 22 January 2025

Final report submitted to organisation: 22 January 2025

Publication reference: PRN01548