Executive Summary
Overall, feedback reported from foundation resident doctors in general surgery and trauma and orthopaedics (T&O) was positive. There was good representation from foundation resident doctors in general surgery however attendance from T&O foundation resident doctors was limited.
Positive feedback was shared in relation to the following areas:
- Staffing numbers at night and weekends in T&O was no longer being described as unsustainable. The trust has recruited additional locally employed doctors and it was evident that this has had a positive impact as reflected in the feedback received regarding workload.
- Culture in T&O was described as good, and it was reported that resident doctors have had no issues with contacting senior colleagues and getting the support required. Senior colleagues were described by both general surgery and T&O foundation resident doctors as supportive, helpful, and friendly, who encourage and welcome feedback.
- No further concerns were raised by foundation resident doctors regarding facilities. During the educator session, it was reported that there is work ongoing to improve facilities across the trust.
- Foundation resident doctors in urology reported that the department now have their own allocated foundation resident doctors. They advised that they can now attend ward rounds, and handovers have improved. Feedback from the foundation resident doctors was positive about their experience in the urology department.
Foundation resident doctors in general surgery reported that there could be clearer escalation processes in place to help plan next steps for patients between the hours of 1pm – 5pm. It was reported that it can take time to find a senior doctor for advice and they may be busy in theatre. Escalation for medical outliers in general surgery was also flagged as needing some improvement.
Based on the review findings we will be recommending that the Intensive Support Framework (ISF) category 2 is lowered to an ISF category 1. A trust improvement plan will be required against the mandatory requirements outlined in this report that demonstrates suitable actions to address the concerns, supported by demonstrable assurances that this is progressing. We would recommend the trust to encourage completion of the National Education and Training Survey so we can continue to monitor feedback from resident doctors in general surgery and T&O.
Review overview
Background to the review
Foundation resident doctors initially raised concerns regarding education and training in 2018 in general surgery and trauma and orthopaedic surgery (T&O).
Several visits have taken place and at the last visit in November 2023 we were pleased to hear that training and education had improved. We were also assured by educators and the senior team that there was engagement and commitment to continue with these improvements and therefore ISF category 3 for this concern was lowered to an ISF category 2 and removed from GMC Enhanced monitoring.
A follow up visit was organised for September 2024 to review progress for the outstanding mandatory requirements on the improvement plan.
Who we met with
Learner
- Foundation and Higher Resident Doctors in General Surgery and Trauma and Orthopaedics (T&O)
Education Team
- Educators
- Deputy Director of Medical Director
- Director of Medical Education
- College Tutors
- Medical Education Quality Liaison Manager
- Surgical Education Lead
Review panel
All panel members listed below are colleagues from the Workforce, Training & Education directorate at NHS England.
Education Quality Review Lead
- Charlie Mackaness, Head of School, Foundation
Specialty Expert
- Dr Roger Kunkler – Associate Postgraduate Dean
Other panel members
- Dr Manjula Pammi – Deputy Foundation School Director
NHS England Education Quality Representatives
- Kerry Olley, Quality Deputy Manager
Review overview
Review findings
Escalating concerns – General Surgery
Foundation resident doctors in general surgery reported that there needs to be clearer escalation processes during the hours of 1pm – 5pm. It was reported that there can be delays with escalating concerns and getting a plan in place for the patient, particularly if they were not involved in the ward round on the general surgery ward in the morning. They did confirm that they know who to escalate to but reported that it can take some time as quite often, the higher resident doctors can be busy in theatre. It was reported that this has already been raised with senior colleagues in the department and they are already looking at ways to improve the escalation process. Foundation resident doctors added that during out of hours however, there are clear escalation processes in place with a dedicated on-call team.
It was reported that senior colleagues welcome feedback and overall, it has been a positive experience for the new foundation resident doctors in general surgery.
Foundation resident doctors in general surgery also reported that escalation processes are not clear for medical outliers. They confirmed that if they miss the medical consultant doing the ward rounds in the morning then they need to review the notes which are not always clear. It was reported that at times they need to go to the medical ward for help to try and clarify the plan for the patient.
Workforce/Ward Rounds – T&O
Workload on the ward rounds was described as varied, but it was reported that improvements have been made, particularly now that the trust have recruited additional locally employed doctors. Overall, it was reported that ward rounds are working well, and foundation resident doctors are well supported by colleagues and senior colleagues. The transition into this post was described as easy and resident doctors reported a positive experience so far in T&O.
It was reported that there are days where it can be extremely busy but there is sufficient support on the wards including out of hours and at weekends. It was reported that at times it can be hard to log everything on the e trauma logbook for the patients, so occasionally, the foundation resident doctors need to stay after the shift to finish this. They did however add that on other occasions it can be quiet in the department. It was reported that the workload varies depending on how busy the referrals are from the accident and emergency department.
General surgery foundation resident doctors also reported that now there are more foundation year one and year two resident doctors, they are not having to go from one ward to another, and each ward has an allocated foundation resident doctor which was reported as being a positive change.
Urology
At the previous visit, foundation resident doctors reported that they did not always receive a clear handover and context for the job when they had to cover urology, however, since the previous visit urology now have their own foundation resident doctors in post. Two foundation resident doctors are allocated to urology which has helped, and it was reported that they now feel part of the team. Educators added that the feedback they have received so far for these new posts has been positive.
Overall, the handover Web V system is working well in urology, and they review it before they see the patients. Foundation resident doctors reported that they now attend the ward rounds so they have a better understanding of the next steps for the patients.
Culture – T&O
The culture was described as good in T&O. Foundation resident doctors reported that middle grade doctors are ‘really supportive’, and foundation resident doctors reported that they feel comfortable asking questions.
It was reported that the handover trauma meeting works well, and foundation resident doctors are given the opportunity to present. It was reported that if they admitted patients unnecessarily, they viewed it as a learning experience and received constructive feedback explaining why the admission was not needed.
Facilities
Foundation resident doctors raised no further concerns regarding facilities.
Teaching
Foundation resident doctors in general surgery reported that departmental teaching takes places every Wednesday which was highly praised. They reported that the sessions are beneficial, and they all get the opportunity to present and teach. They added that due to commitments on the wards they are attending approximately 80% of the sessions available to them.
Areas that are working well
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
| Workforce/ward rounds Staffing numbers at night and weekends in T&O was no longer being described as unsustainable. The trust has recruited additional locally employed doctors, and it was evident that this has had a positive impact as reflected in the feedback received regarding workload. Urology At the previous visit, foundation resident doctors reported that they did not always receive a clear handover and context for the job when they had to cover urology, however, since the previous visit urology now have their own foundation resident doctors in post. Two foundation resident doctors are allocated to urology which has helped, and it was reported that they now feel part of the team and educators added that the feedback they have received so far for these new posts has been positive. | 1.5 |
| Facilities No further concerns were raised by foundation resident doctors regarding facilities. During the educator session, it was reported that there is work ongoing to improve facilities across the trust. | 1.11 |
| Culture Culture in T&O was described as good, and it was reported that resident doctors have had no issues with contacting senior colleagues and getting the support required. Senior colleagues were described by both general surgery and T&O foundation resident doctors as supportive, helpful, and friendly, who encourage and welcome feedback. | 1.3 |
| Teaching Foundation resident doctors in general surgery reported that departmental teaching takes places every Wednesday which was highly praised. They reported that the sessions are beneficial, and they all get the opportunity to present and teach. | 1.4 |
Requirements
Mandatory requirements
| Requirement reference number | Review findings | Required action |
|---|---|---|
| Escalating concerns – General Surgery | Foundation resident doctors in general surgery reported that there needs to be clearer escalation processes between the hours of 1pm – 5pm. It was reported that there can be delays with escalating concerns and getting a plan in place for the patient, particularly if they were not involved in the ward round on the general surgery ward in the morning. Foundation resident doctors in general surgery also reported that escalation processes are not clear for medical outliers. | The trust needs to ensure clear escalation processes are in place, so the foundation resident doctors know how to contact the senior doctor. The trust needs to ensure there are clear escalation processes in place for medical outliers on the general surgery ward and foundation resident doctors are aware of the process. |
Report approval
Report completed by: Kerry Olley, Quality Deputy Manager
Review lead: Charlie Mackaness, Head of School, Foundation
Date signed: 11 October 2024
NHS England authorised signature: Andy Whallett, Postgraduate Dean
Date signed: 24 October 2024
Final report submitted to organisation: 20 November 2024