Executive summary

Overall, resident doctors shared a variable experience regarding their training within the department. 

The following are areas identified during this visit that are working well or showed improvement: 

• Resident doctors shared more positive feedback about their interactions with the consultant body. Consultants were also able to share detailed insight into the issues raised by resident doctors about training in the department.
• Improvements were noted to the behaviours of the multi-disciplinary team (MDT) at Birmingham Heartlands Hospital (BHH).
• Staffing has improved within areas such as triage at both sites of the trust, which is providing additional clinical support to resident doctors.
• All resident doctors shared praise for their educational supervisors. They were reported to be supportive and delivered timely feedback against performance.
• Resident doctors reported that supervision from consultants during antenatal clinics has improved.
• Resident doctors reported that they are no longer being asked to write discharge letters for patients they have not seen.
• Resident doctors reported that they feel encouraged to raise concerns by the consultant body.

There were reports of ongoing concerns which require further improvement:

• Concerns continue to be shared by resident doctors about the process within obstetric triage. Resident doctors reported being frequently pressured by non-clinical staff to leave other areas to review patients who are about to breach timescales. This was said to be impacting on adequate opportunities for training.
• All resident doctors raised concerns about the ongoing poor behaviours being displayed by the Midwifery team at the Good Hope Hospital (GHH) site towards themselves and the consultant body.
• Resident doctors continued to report concerns about the rota not being conducive to their training needs. This situation appears to be occurring because of a lack of input into the rota by resident doctors undergoing the WT&E training pathway.
• There is a perceived lack of training and teaching opportunities for resident doctors due to upholding service provision.
• It was reported by resident doctors and consultants that access to clinics is still an issue, with resident doctors expressing concern about being able to meet curriculum requirements.
• Concerns continue to be raised by resident doctors about the variable approach to, and respect for, training amongst the consultant body.

In addition to the above, the following new areas of concern were noted which will require action: 

• Resident doctors shared concerns regarding the level of senior support being provided in the postnatal wards.
• Resident doctors reported negative feedback about the behaviours of some consultants towards each other.
• Resident doctors shared their concerns that there are known gaps in the tier 3 on call rota, which are not always proactively addressed once they are identified. This was perceived by resident doctors on the tier 2 rota to impact on their workload and the support available to them.

Overall, feedback from this visit highlighted that there have been some improvements to the training experience for resident doctors. However, we recognised that attendance from tier 2 level resident doctors was suboptimal, and it was not clear how the trust had facilitated team members to join the sessions and share their experiences with us. In addition, progress against some of the outstanding issues has been slower than expected and further work is required to evidence that tangible change has been made in these areas. 

To ensure that the required improvements are fully embedded, and the outstanding areas of concern are addressed, the Intensive Support Framework (ISF) category of 3 and General Medical Council (GMC) Enhanced Monitoring will be maintained for this concern. The item will remain on the Quality Improvement Register. 

The GMC will confirm any changes to conditions applied on obstetrics & gynaecology training at the trust as appropriate. 

A trust improvement plan will be required against the mandatory requirements outlined in this report.

Review Overview  

Background to the review

This quality visit was held as a follow-up to the November 2023 learner educator meeting to test progress against the trust’s active improvement plan for postgraduate medical training within obstetrics and gynaecology.  

Who we met with

Learners

• Resident doctors within obstetrics and gynaecology at the following levels: Foundation level
  • General Practice
  • Tier 1 resident doctors: working at specialty levels (ST) 1–2
  • Tier 2 resident doctors: working at specialty levels (ST) 3–7

Educators

• Consultants within obstetrics and gynaecology

Education team and senior team

• Medical Director for Education
• Deputy Medical Director, Medical Education (DME)
• Head of Postgraduate Medical Education
• Senior Quality Manager
• Quality Manager
• Clinical Tutor
• Clinical Service Lead
• Education Operations Lead
• College Tutors
• Head of Medical Academy
• Postgraduate Centre Manager

Review panel

• Education Quality Review Lead – Andrew Sizer, Head of School, Postgraduate School of Obstetrics and Gynaecology
• Specialty Expert – Tony Thomas, Training Programme Director, Postgraduate School of Obstetrics and Gynaecology
• NHS England Panel Member – Rabia Imtiaz, Medical Director System Improvement and Professional Standards
• NHS England Education Quality Representative – Amelia Harbon, Quality Deputy Manager, Education Quality team
• General Medical Council (GMC) representatives:
  • Jamie Field, Education Quality Assurance Programme Manager
  • Craig Steele, Enhanced Monitoring Associate

Review findings

To support the findings of this report, it should be noted that within the trust rota

arrangements, tier 2 resident doctors are split into two grades: the middle grade rota (ST3–5) and the senior grade rota (ST6-7).  

Culture – GMC Enhanced Monitoring condition

Resident doctors shared that overall, they had identified improvements to the multidisciplinary culture across the department at BHH. Members of the MDT were reported to be approachable and supportive, with help being available to resident doctors when it is required. However, resident doctors advised that on occasion, some consultants will share negative feedback about the clinical decisions of their peers in the presence of patients. Resident doctors felt that this behaviour evidenced some of the challenges the trust is facing with resolving the identified cultural concerns.  

Resident doctors continued to raise significant issues about the culture at GHH, with emphasis placed on a theme of poor behaviours being displayed by the midwifery team. Several examples were shared by resident doctors where they had either directly experienced, or witnessed these behaviours which they described as ‘bullying’ and ‘berating’. 

Some resident doctors also felt that the midwives particularly undermine those who are at tier 1 level. This was said to be taking place where tier 1 level resident doctors had recently rotated into the department and required a period of time to familiarise themselves with their role and the clinical areas. 

All behaviours being experienced were reported to be negatively affecting the wellbeing of resident doctors, as well as impacting on the cohesiveness of the multi-disciplinary team at the GHH site. Some resident doctors shared that regular meetings are being scheduled with senior leaders to discuss behavioural concerns however, it appeared that not all resident doctors were aware of this meeting taking place. The Education team shared that they are continuing to implement several actions across both sites to support the ongoing concerns regarding culture and behaviours. This includes a ‘you said, we did’ approach to Resident Doctors Forums, and piloting a ‘team of the shift’ model. This allows resident doctors to introduce themselves and share their training needs with the multi-disciplinary team during handover. Resident doctors recognised the implementation of the team of the shift initiative however, felt it was ‘too early’ to advise whether it had been successful, with wider roll out needed. 

In addition, the Education team confirmed that the appointed Chief Residents are invited to internal, multi-disciplinary meetings to support the improvements to training within the department. This was said to allow feedback from resident doctors to be listened to and acted upon on a routine basis. The Chief Residents are then required to share any discussions or agreed actions from the meeting to resident doctors to close the feedback loop. 

Raising concerns (this had been identified as a previous mandatory requirement at our visit in November 2023)

In line with the findings of our November 2023 visit, all resident doctors reported an awareness of how to raise concerns, sharing that there are multiple mechanisms available to share feedback. Resident doctors shared that the consultant body encouraged them to raise concerns, and there was more confidence that feedback is being appropriately actioned.

This feedback was echoed by the consultants, who advised that they escalate the concerns raised by resident doctors through the relevant pathways for a response. 

Teaching (this had been identified as a previous mandatory requirement at our visit in November 2023)

At our last visit in November 2023, concerns were raised by resident doctors about not being able to attend teaching sessions due to upholding service provision. During this visit, there were no concerns reported by resident doctors about not being able to attend teaching sessions. 

Learning opportunities (this had been identified as a previous mandatory requirement at our visit in November 2023)

Across both sites, resident doctors continued to report concerns about getting regular opportunities to train, sharing that they felt that this was impacting on their ability to fulfil their curriculum needs. Resident doctors felt that this issue was due to problems with the rota and the requirement for them to support service provision. 

There were reports of challenges with access to clinics as a training opportunity. Some resident doctors shared that, although clinics had been rostered into their shifts, they had only been able to attend once since they had started their rotation. This was due to being pulled to support service provision in other clinical areas. In addition, tier 2 level resident doctors shared that whilst access to hysteroscopy procedures is adequate, opportunities to undertake other procedures, such as laparoscopic and open procedures is suboptimal. Resident doctors advised that they were concerned about their ability to evidence adequate experience in clinics within their curriculum competencies.

The Education team confirmed that the exercise to create a training matrix to identify the learning needs for resident doctors at different levels had been completed, with the matrix now in use to support the rota. However, they also recognised that there are still issues when resident doctors are being pulled away due to service pressures, and further work is required to resolve this concern. 

Concerns were also reported regarding the patient review process within the obstetric triage area. All resident doctors shared that they are regularly pressured by non-clinical staff to leave training opportunities to review patients who are about to breach timescales. The trust has implemented an additional doctor to support triage during the day, which resident doctors reported has helped alleviate some of the pressure on them. However, resident doctors shared that during the night, triage lacks a dedicated doctor. This means doctors in obstetrics are frequently pulled into triage to provide cover. Tier 1 level resident doctors reported that this caused them to regularly miss ward rounds, as well as the wider resident doctor group advising that it affected their labour ward training experience. 

In addition, resident doctors on the senior grade rota reported regular challenges with completing advanced training skills modules (ATSMs) and specialist interest training modules (SITMs). This is due to supporting the needs of the service. 

Rotas and workload (this had been identified as a previous mandatory requirement at our visit in November 2023)

All resident doctors continued to report concerns about the rota, sharing that it is not currently supporting their training needs. We identified that this situation appears to be occurring because of a lack of input into the rota from resident doctors at various levels of the WT&E training pathway. 

Whilst staffing has continued to improve across both sites, there were reports from resident doctors of known gaps in the tier 3 level rota, which are not always proactively addressed once they are identified. On occasion, this has meant that those on the junior level of the middle grade rota are required to act up to senior level during on call shifts. While consultant support is available, there were reports that some of the consultants are based in the office rather than being in the clinical areas, which was highlighted as a concern for resident doctors.

In addition, resident doctors reported regularly experiencing last minute changes being made to the rota. It was shared that often they were only made aware of these changes the evening before, or on the day of the shift in question. 

Specific concerns were also raised by all resident doctors about the workload and level of senior cover available in the postnatal ward area at BHH. A resident doctor described the workload on postnatal as ‘overwhelming’ and shared an instance where the only doctor available in the postnatal area was tier 1 level and was expected to cover three wards without senior support. Other resident doctors agreed, noting that there does not appear to be a formal postnatal ward round process in place. They advised that consultants often attend the area to review admitted patients and then leave without further support or offers of teaching. Resident doctors felt that these issues were occurring due to a lack of clinical input into the rota cover in the ward areas. 

When we spoke with the consultant body, they recognised the feedback being shared by resident doctors and advised that an audit is currently in progress within the ward areas to review consultant cover. In addition, the Education team shared that seasonal sickness across the department has meant that patient safety needed to be prioritised, with an increase in the amount that resident doctors have been required to support the service. 

Disconnect between the consultant body and resident doctors (this had been identified as a previous mandatory requirement at our visit in November 2023)

Resident doctors reported that they have noted improvements to the clinical support offered by consultants. When resident doctors have had the opportunity to attend clinics, they noted that there is better consultant supervision available. 

However, we were told by resident doctors that, across both sites of the trust, they feel only 50% of consultants want to teach and value medical training. Whilst positive experiences were shared of individual consultants in antenatal clinics at BHH and during gynae procedures at GHH, resident doctors felt that this was consultant dependent, rather than being a general approach adopted by the team.    

Resident doctors praised consultants who are recognised as educational supervisors, highlighting their feedback as timely and regular, which allows them to improve their performance. The Fetal Medicine team at the trust were also commended by the resident doctors for their support and dedication to teaching.

The Education team are aware of the feedback provided by resident doctors about the variable support offered by consultants. They shared an approach that they will be taking whereby they utilise consultants that are keen to teach to train the resident doctors. This should improve the experience of resident doctors within the department. 

Disconnect between the consultant body and the trust (this had been identified as a previous mandatory requirement at our visit in November 2023)

Following the visit in November 2023, we reported a disconnect between consultants, in recognising the issues raised about training within obstetrics & gynaecology, and the work being undertaken by the trust. Improvements were identified at this visit, with the consultant body sharing a detailed insight into the issues being raised by resident doctors. Consultants also shared an account of the ongoing work being undertaken to address the issues, including how they were actively involved with supporting the improvements.  

Curriculum requirements

(this had been identified as a previous mandatory requirement at our visit in November 2023)

At our last visit, resident doctors reported occasions where they felt their learning needs had not been recognised, and there was a need to balance providing opportunities to different groups of doctors. This was to ensure that they could provide sufficient evidence at their Annual Review of Competence Progression (ARCP). 

During this visit, there were no concerns reported by resident doctors about the management of their learning needs with other groups of doctors. The Education team also provided reassurance regarding how equity of training opportunities is managed between different groups of learners to contribute to their curriculum requirements. 

Discharge summaries process (this had been identified as a previous mandatory requirement at our visit in November 2023)

In November 2023, resident doctors told us about a process whereby they would complete patient discharge paperwork for patients they may not have clinically reviewed. This process was undertaken to allow patients to be more easily discharged. During this visit, resident doctors reported that they have not been asked to complete discharge paperwork for patients they have not seen, and provided reassurance that they would not do this if they were asked, to ensure patient safety is maintained. 

Areas that are working well 

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Amelia Harbon, Quality Deputy Manager
Review lead: Andrew Sizer, Head of School, Postgraduate School of Obstetrics and Gynaecology
Date approved by review lead: 7 February 2025

NHS England authorised signature: Prof. Jonathan Corne
Date authorised: 5 March 2025

Final report submitted to organisation: 25 March 2025