Executive summary

The Workforce Training and Education directorate of NHS England (Midlands) have been meeting with resident doctors in Obstetrics and Gynaecology (O &G) at Lincoln County Hospital since concerns were raised in May 2021 regarding their education and training. In the most recent visit, overall, resident doctors spoke positively about almost all aspects of their education and training. They particularly highlighted the efforts made by the College Tutor to make positive changes to improve their training experience.

Resident doctors described most consultants and all the midwives as friendly and welcoming.  They felt that the department provides safe care, and all were comfortable in raising concerns.  They reported an extensive induction and a manageable rota.

Positive feedback was shared in relation to previous issues raised:  

• Efficient structure now in place to manage clinic workload including excellent supervision
• Manageable workload out of hours and reduced pressures with an additional resident doctor now on the rota
• Good educational supervision
• Improved learning opportunities.

Whilst the overall learning opportunities described by resident doctors had greatly improved, opportunities for gynaecology surgery are impacted because lists are being cancelled due to staff shortages.  Although many issues with IT access have been resolved, both resident doctors and educators described the computer systems as frustratingly slow and negatively impacting productivity.  It was also noted that not all resident doctors appeared to be aware of how to exception report.

To summarise the areas to be addressed by the trust are as follows:

• Opportunities for gynaecology surgery lists
• Clinical systems and IT
• Exception reporting

Overall, the panel were assured by the feedback, and it was evident that the consultants, the education team and the business unit have taken steps to address long standing issues. The commitment to provide a good training experience in the department was recognised. 

Based on the review findings we will be recommending that the ISF category 2 is reduced to an ISF category 1. A trust improvement plan will be required against the mandatory requirements in this report to provide further assurances that actions already in place are progressing. 

Review overview

Background to the review

Initial concerns regarding O&G training at Lincoln County Hospital were highlighted to the Postgraduate Head of School in May 2021, and the 2021 National Education and Training Survey (NETS) outcomes supported these concerns.   

Health Education England first met with resident doctors and educators in October 2021 to explore the concerns further. Following the visit, the trust shared an improvement plan to address the identified issues within O&G training which included excessive workload, a lack of consultant support, variable access to educational supervisor meetings and unrealistic expectations placed on resident doctors.  

Although subsequent meetings in December 2021, June 2022 and October 2023 highlighted some improvements to the quality of training, they identified a lack of progress in addressing some of the concerns raised. The trust has continued to provide updated improvement plans, and it was agreed that a further visit would be undertaken to seek assurance of progress on the outstanding areas of concern including:

• Workload in clinics
• Clinical systems & IT
• Workload out of hours
• Educational supervision
• Learning opportunities

Who we met with

Learners

• Resident doctors in O & G

Educators

• Clinical and Educational Supervisors in O & G

Education team

• Director of Medical Education
• Deputy Director of Medical Education
• Assistant Director of Education
• Medical Education Quality Liaison Officer
• Divisional Lead
• College Tutor
• Managing Director for Family Health

Review panel

• Dr Alec McEwan, Head of School, O & G
• Dr Judith Moore, Training Programme Director, O & G
• Sarah Wheatley, Quality Deputy Manager

Review findings

Learning Environment and Culture

Overall resident doctors spoke positively about their training and education experience at Lincoln County Hospital. All resident doctors highlighted the appointment of the new College Tutor, recognising their positive impact, and were appreciative of the efforts made to make changes to improve their training experience.  

The consultants and midwives were described overall as friendly and welcoming. However, there were a small number of isolated examples given where they felt a minority of the consultants were not as friendly and welcoming as others. We were reassured in the feedback session that the culture of the organisation is a priority for the trust and extensive work is being carried out around civility.

All resident doctors felt that the unit provided safe care and said they would feel comfortable in raising concerns about patient safety if they needed to. They reported a comprehensive induction with time given for system training, and a manageable rota. Resident doctors are given regular administration time which they appreciated and envisaged no issues in getting time for audit work when this is required. They found the rota consultant very approachable and felt that if they were struggling with administration time this would be accommodated.

Resident doctors also discussed areas where they thought improvements could be made, including having a board for patient jobs instead of a clipboard carried around by the midwife. 

Clinics

Resident doctors described excellent supervision in clinics and reported that there is always a consultant present. They reported that clinics are now structured in a much more efficient way with structured templates to enable midwifery led management for some of the clinics. This has reduced the consultant clinic numbers which has allowed an increased amount of time for discussion with the consultant and time for work-based assessments such as MiniCEX and continued professional development (CPD) activities. They recognised this structure as being unique to the region and felt things were working efficiently and are rarely leaving late from clinics.

Clinical systems and IT

Resident doctors described an extensive induction with almost all new starters getting access to clinical systems in a timely manner with good support from IT. Both resident doctors and educators all described the systems and computers as frustratingly slow and negatively impacting productivity. In the educator session it was acknowledged that the trust recognises this and are taking actions including the introduction of a single log in system.

Workload out of hours

Resident doctors described the workload out of hours as manageable and reported that the additional resident doctor starting has had a positive impact.

They reported the consultant support out of hours as good overall, however, described mixed experiences when calling them out of hours with some being described as less happy than others to be called. They reported finding the communication tool helpful which makes it clear to consultants if resident doctors are calling them for advice or if they want them to come into the hospital.  

Resident doctors did highlight some frustrations with the delays in morning handover. It was reported that due to a cross-site multi-disciplinary safety huddle taking place prior, the handover was often delayed in starting, resulting in those that have worked the night shift leaving late. When asked if they submitted exception reports for late finishes, not all resident doctors appeared to be aware of the process. In the educator session we heard that the delays in handover have been raised with the Head of Midwifery and addressed.

Educational Supervision

All resident doctors spoke positively about educational supervision and the availability of the educational supervisors, with one describing their experience as ‘amazing’.

Educational supervisors reported feeling well supported, they have time in their job plans and felt they were able to deliver what is required. They did raise some difficulties with accessing the trust educational supervisor training sessions because of a lack of availability. Some reported undertaking the online training which they described as arduous, whilst some were paying for sessions which they described as being ‘low quality but ticked the box’. In the feedback session, the Director of Medical Education reported that more inhouse courses are to be organised.

Learning Opportunities

All resident doctors described the learning opportunities as good. However, resident doctors and educators reported that although the cancellation of operating lists had somewhat improved, the gynaecology lists do still get cancelled due to staff shortages which impacts learning opportunities. Resident doctors also reported on occasion having their names removed from theatre lists to accommodate newly appointed consultants. In the educator session it was reported that, along with the surgical division, a business case is being developed to recruit additional theatre staff to expand the elective work and there is an ongoing increase in consultant numbers.

Resident doctors appreciated working with the same consultants on a regular basis and felt that consultants maximised the opportunities for learning when in theatre. Overall, they felt that all resident doctors were able to get good learning opportunities.

Areas that are working well

Good practice

Areas for improvement

Mandatory requirements

Report approval

Report completed by: Sarah Wheatley, Quality Deputy Manager
Review lead: Dr Alec McEwan, Head of School, O & G
Date approved by review lead: 2 November 2024

NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean
Date authorised: 12 November 2024

Final report submitted to organisation: 2 December 2024