Executive summary

NHS England Workforce Training and Education South East visited University Hospital Southampton (UHS) on 23 October 2024 to review the experience of foundation doctors, core surgical resident doctors, higher surgical resident doctors and trainee advanced clinical practitioners. This followed previous visits in 2022 and 2023 where significant concerns were raised. This visit was intended to assess whether the experience of these learner groups has improved following the work done by UHS since the end of 2023.  The General Medical Council (GMC) was part of the visit as surgery at UHS is in GMC enhanced monitoring.

Overall, the panel found that the experience of learners in surgery has improved although there are some concerns remaining. The doctors and advanced clinical practitioners in training we spoke to describe a more friendly environment, improved induction in many areas, a better rota and workload and almost all experienced better behaviours within the area.    

We did pick up on some specific concerns that remained including some recent conflict between higher specialty resident doctors and advanced clinical practitioners in one area and one episode of bullying racist behaviour by an individual resident doctor.  It is acknowledged that a number of the interventions undertaken by the trust post dated these reports, and the individual doctor cited has left the trust.

Whilst workload was generally better, urology is still difficult and UHS are sighted on this and raised it in the first session.  Induction for cross cover of other areas out of hours is not clear and it was notable that the core surgical resident group would not recommend their training.  Educators are frustrated about feedback levels and space for learning. There is a question about the future of the rota in ENT.

A number of learner groups we spoke to had only been given one or two days’ notice of the review and the invitation to attend, although the engagement was generally good.

The panel acknowledged the significant effort and engagement the department have made to improve the experience of learners in surgery since the previous and this is evident in the improved feedback.

No new mandatory requirements were identified as a result of this review, but a number of recommendations are included in this report. The report will be shared with UHS and a meeting arranged to follow up on recommendations. NHS England will review the existing education quality risks held relating to this area and the GMC will review the enhanced monitoring status and provide an update to UHS. 

Review overview

Background to the review

In December 2023 NHS England Workforce Training and Education (WT&E) undertook an education quality intervention, jointly with the GMC, to review the experience of foundation doctors and trainee advanced clinical practitioners in surgery at University Hospital Southampton. Previous visits to surgery at UHS in March and November 2022 identified four specific areas of concern.

During the education quality review of December 2023 significant concerns were raised relating to inappropriate behaviours and escalation pathways which included senior staff not being contactable. Recent data via the GMC National Training Survey (NTS) show multiple below outliers at both a programme and post specialty level for trainees and for trainers, and data from the NHS England National Education and Training Survey (NETS) showed below outliers in two areas.

This follow-up review is intended to assess the experience of resident doctors including foundation, core and higher surgical grades and trainee advanced clinical practitioners in surgery at UHS in light of the work undertaken in response to the mandatory requirements and recommendations included in the previous report.

Who we met with

Learners:  7 trainee advanced clinical practitioners, 11 foundation year 1 resident doctors and fellows, 4 foundation year 2 resident doctors and fellows, 7 core surgical resident doctors and 11 higher surgical resident doctors and fellows. A small number of these learners joined remotely.

Educators: 5 supervisors of advanced clinical practitioners, approximately 15 consultants with educational or clinical supervisory roles for resident doctors.

Trust senior team, including:

• chief executive
• chief medical officer
• deputy chief medical officer
• director of medical education
• director of education and workforce
• chief people officer
• divisional clinical director
• guardian of safe working
• divisional director of medical education
• care group clinical lead
• surgical college tutor
• divisional director of operations

Evidence utilised

• output of previous visit, December 2023
• National Education and Training Survey (NETS) results
• GMC National Training Survey (NTS) results

Review panel

• Education quality review lead: Dr Paul Sadler, Regional Postgraduate Dean
• Specialty expert: Dr Liz Williams, Deputy Head of Foundation Schol
• Specialty expert: Mr Simon Sleight, Head of School of Surgery
• Specialty expert: Heather Nisbet, Faculty of Advancing Practice
• GMC representative: Lucy Llewellyn, Education Quality Assurance Programme Manager
• Education quality representative: Caroline Lee Head of Education Quality
• Lay advisor: Sushant Daga
• Education quality representative: Nikkie Marks, Education Quality Manager
• Education Quality representative: Sarah Lang, Education Quality Support Administrator

Requirements

Mandatory requirements

No mandatory requirements were identified.

Recommendations

Review findings

Trust senior team

We met with a large group of senior UHS staff who summarised the work that has been undertaken to address the concerns raised following the education quality review visit in late 2023.  This included an anonymous survey and facilitated workshops for all consultants, review of specific issues and sharing of the report across multi-disciplinary teams. There is an ongoing wider cultural piece across surgical groups and operating theatres. An acute conflict resolution course was held, and an educational handover policy developed, an audit of which was subsequently presented as a poster.  The foundation year 1 (FY1) rota has been increased and rewritten, with a consultant lead, with twilight shifts and ASU clerking shifts introduced. An audit of FY1 exception reports has shown a decrease since its introduction.  The rota for foundation year 2 doctors (FY2) and core resident doctors has also been redesigned, a journal club introduced, and a new resident doctor’s office secured. Work to clarify the scope of practice of advanced clinical practitioners has also been undertaken together. The panel also heard that consultant and registrar of the week systems have been introduced across many areas. 

The senior team expected that we would hear an improved position from learners but also highlighted some areas, such as high workload in urology, that they are aware remain challenging and would likely be raised.

Trainee advanced clinical practitioners

This group of learners reflected on how the lack of understanding of the roles of different grades of advanced clinical practitioners at different stages of training remains unclear.  We also heard about ongoing work to add profiles to foundation year 1 induction information to try to highlight this. 

The learners felt that training is more inclusive now than it was previously, and they value opportunities such as being able to attend the newly set up journal club. We heard that there is plenty of opportunity for learning if you actively seek this out although some did not feel as involved in teaching. 

Frustration was raised with the University of Southampton pathway where it was highlighted that the competency booklet is not up to date and there is a lack of clear guidance about what needs to be signed off and when.  In acute surgery, we hear that there is no job plan in place, and it was felt that the balance of work is not good.  

Some tensions with registrars were reported. The group agreed that they had not experienced or witnessed unprofessional behaviours. 

Educators – advanced clinical practitioners

The group reported that they do feel supported as educators for this group but reflected on the time pressures involved with an increasing overall burden of supervision and there has been an element of having to learn some of the advanced clinical practitioner programme specifics as they have progressed, without an initial induction to it.  The Open University (OU) and University of Southampton (UoS) pathways are very different which adds a burden of complexity in supervising.  The OU ACP MSc is no longer running so the issue of differing pathways will lessen with time.  Time for training is included in job plans for consultant surgeons as part of SPA time and as a part of AfC band 8a and above job plans but without a time allocation.

Some ACP supervisors reported up to seven trainees – this is more than is recommended in the Centre for Advancing Practice minimum standards for advanced practice supervision and is a requirement for NHS England funding for advanced practice pathways. However, they did use an integrated approach to supervision with the use of associate supervisors to lessen the burden although it remains a lot of supervisors to manage in the time allocated in job plans.

The trust is still working on competency frameworks for advanced clinical practitioners and progress is being made.  It was noted that there is not current a trust level ACP lead.

The input of the consultant working on rotas was positively noted and the group were aware of, and involved in, the cultural work across surgical areas. 

Foundation year 1

The group shared a mixed picture around induction with some, particularly HPB, reporting good induction with support from ACPs and that the handbooks were helpful. Shadowing in ASU was well received.  Foundation fellows either did not have a formal induction or described it as poor. 

The resident doctors in HPB, colorectal, upper GI and urology told us they felt very supported by ACPs, registrars and consultants and were able to escalate when needed.  They had consultant and/or registrar of the week systems in place. In ASU this was less clear with the set-up of SDEC also affecting escalation as the ANP can be pulled away and the registrar was not visible until the recent change of cohort.

The group fed back on the changes that have been made to rotas and were very positive about the consultant leading this. They described the handover to the new twilight shift as being informal, with the formal handover occurring at midnight. They did highlight some confusion around the transfer of the bleep to the twilight shift at 4pm but were all positive about the twilight shift (4pm to midnight) itself for the learning opportunities it provides. In urology, the resident doctors had escalated concerns the day prior to the visit about the number of shifts covered by one foundation year 1 and one ANP only which means they are not able to get to surgical teaching or the journal club. Cross covering specialties out of hours was described as difficult; there are no ANPs on Sundays and these shifts are very busy.

Resident doctors were, in general, encouraged to exception report where applicable, were able to attend foundation teaching sessions, had their self-development time (SDT) included in the rota and had all met their educational supervisors. Pastoral support was provided in departments with urology particularly positively mentioned. 

No concerns were raised when asked about the working atmosphere and none of the group had experienced issues with sexism.

When asked, most would recommend their post with some reservations including that they would not recommend in urology due to the high workload, and that they would like to see more teaching on ward rounds and some access to theatre time.

Foundation year 2

When asked about their induction this group reported that colorectal was good and ASU is improved. The group reported receiving rotas on time and that known gaps in rotas are proactively addressed.    

The workload was described as busy but not overwhelming and there have been some positive changes where staffing levels have increased such as ASU. In some areas resident doctors are able to submit exception reports but other reported that they do not know how to do this.

All the resident doctors have clinical and educational supervisors that they have met but there had been delays to this for some initially. SDT is timetabled.

The group felt confident at present to escalate concerns, people are approachable, and current registrars are generally easy to get hold of. However, it was reported that the outgoing colorectal registrar(s) were previously an issue in terms of behaviour towards foundation doctors, including telling them not to take advice from ACPs which led to delays in decisions and communications. There was also an allegation of bullying and racist behaviour. The situation is different with the current group of registrars and working relationships are better.

Handovers work well especially when this is within a subspecialty, it is harder when done across specialty.  The culture of handovers is good. Access to surgical teaching, journal club and foundation teaching is good.

The group noted that they only had information about this NHS England/GMC visit two days ahead of time and without any context.

All would recommend their post to others.

Foundation resident doctors in vascular and cardiothoracic areas attended this session as they were invited to do so.  The panel acknowledge that they are in different departments and are managed separately but their feedback is reported here. Both of these groups reported that they did not receive a clear induction. In vascular surgery the rota was reported to be wholly ward based with no scheduled time in clinics or theatres and the resident doctors in vascular surgery would value some theatre time. The vascular handover was praised, and the additional registrar noted. 

Core surgical residents

This group of resident doctors also gave a mixed picture about the local induction process. In general surgery, they were not expected so the induction was not planned. In other areas, urology, upper GI, paediatrics and ENT the induction as better. Some resident doctors told the panel they did not get induction covering maxillofacial work out of hours cover although UHS confirm that an appropriate induction was provided that included maxillofacial surgery. The Wessex Head and Neck course was good.

We heard that the core surgical residents received their rotas late and that there is no communication between general and vascular surgery about rotas which results in conflicts in commitments. There were very late changes around two weeks prior to start as the new design was implemented and some have found it difficult to get cover even with significant advance notice.  Study leave for exams is proving an issue.

When specifically asked about behaviours they have seen and experienced the resident doctors told the panel that, in some lists, they are competing with anaesthetic trainees, and they do not feel that there is the same culture of support for training from trainers in surgery that they observe in anaesthetics. They also described feeling pressured from other members of the wider theatre team and hearing nursing teams talking about them after lists. They did not feel comfortable raising this concern.

There was very positive feedback about the culture and approach to training in the urology area and no concerns were raised in other areas. The resident doctors had clinical and educational supervisors and had met them.

The group would not recommend their post for this level of training.

As with the group above, resident doctors in vascular surgery were invited to join the group so their feedback is reflected here. The panel heard that induction was not planned as they were not expected.  There was very positive feedback about the culture and approach to training in the vascular area and training here was clearly recommended.

Higher surgical residents

The panel were aware that many of this group have only been in post at UHS for around three weeks so acknowledged this at the start and recognise that the feedback will be based on this period. The early impressions of many were good, describing being welcomed and friendly teams. One had been in the trust for longer and was very positive about their experience with good access to surgical experience.

There was mixed feedback about local induction with some areas, such as colorectal and urology where it wasn’t felt to be helpful and many where IT access was difficult requiring a lot of chasing to get fully set up. A checklist of all required systems was suggested to allow this to be sorted early in a post. Rotas were reported to have been sent slightly late and in some cases were a screenshot. The group reported still being asked to cover rota gaps for on calls even though there are more on the rota now. A concern was raised about one rota that has five long days which was believed to not be compliant as it has not been locally agreed. 

There was good feedback relating to accessing clinical and educational supervisors, with most having already met their supervisors. Access to teaching and to booking leave was ok.

We heard that the role in ASU is believed to have changed, having previously been very sought after, as it has a lot fewer operating opportunities. At least one of the higher surgical residents said they felt they were taking theatre opportunities from more junior resident doctors.

In terms of behaviours and culture, we heard from one resident that it was better than in previous years. Another reported feeling pressure in theatre to finish cases which affects learning opportunities.

When asked if they would recommend their post, the resident doctors generally gave some qualified support to this but recognised how early in the post many are.

Educators – resident doctors

The educators shared concerns about how well they feel the trust supports them in this role. The panel heard that the many in the group feel they have engaged with the improvement work but have not seen movement from the wider organisation or had clear feedback on progress and some described a disconnect between the board and educators. They raised physical space for education as a key issue and don’t feel there is a strong interest in resolving this at trust level. Some conflict with other groups for training time was also raised. Some felt disempowered or fearful to engage with resident doctors and an example around the Christmas party was given.

The group recognised that the nature of the work and complex patient mix at UHS means training is different to that at many other sites and training opportunities can be limited but that they work to try to identify these. The journal club was well reviewed. A question was raised about the current rota in ENT which was reported to only be funded to February 2025.

There were educators in the group who felt well supported around their work with learners. We heard descriptions of how opportunities for foundation doctors are protected where possible and discussions with core surgical residents to establish where they would like to be placed.

Report approval

Report completed by: Caroline Lee, Head of Education Quality
Review lead: Dr Paul Sadler, Regional Postgraduate Dean
Date approved by review lead: 27 November 2024

NHS England authorised signature: Dr Paul Sadler, Regional Postgraduate Dean
Date authorised: 27 November 2024
Final report submitted to organisation: 10 December 2024

Publication reference: PRN01548