Executive summary
This was a review visit. There have been 17 previous visits to WGH (Weston General Hospital), between 2009 and 2024, both pre- and post- the merger into University Hospitals Bristol and Weston NHS Foundation Trust. These cumulated in a decision to escalate into ISF4 (Intensive Support Framework Level 4) and therefore relocate PGDiT (Post Graduate Doctors in Training) to other specialities or the BRI (Bristol Royal Infirmary) site. At the last visit in November 2023 the review found evidence of further progress, but the current visit indicated deterioration in some areas and improvements in others.
Areas of improvement include handover, induction and access to Supervised Learning Events.
Areas that have mandated requirements for further improvement and work include educational governance, including consistent learning agreements and consistent funding of educational supervision. There must be improvement in ward level clinical supervision for foundation doctors, so that they are safely and appropriately supported according to their level of experience. There remain some unrealistic expectations of what a foundation year 1 doctor is competent to manage without support. Further improvement is required in allocating appropriate learning opportunities in the acute medicine placement of the Internal Medicine Training programme. Staffing challenges have meant that the IMT PGDiT has a high burden of service with poor learning and developmental opportunities. Appropriate learning opportunities in an outpatient clinic are too variable. Local teaching is rated poorly by the PGDiT overall.
Further work is required on job planning for supervisors and development of adequate numbers of supervisors to support learners across the Trust.
None of the doctors present or who submitted their views subsequently would recommend their post to others, nor would they generally recommend treatment in this hospital to friends or family, because of the variability of clinical supervision and dependence on locum senior staff.
In conclusion, further requirements for improvement have been set and will be followed up in a triggered visit review in 12 months.
Review overview
Background to the review
This was a review visit. There have been 17 previous visits to WGH (Weston General Hospital), both pre- and post- the merger into University Hospitals Bristol and Weston NHS Foundation Trust, culminating with a decision in March 2021 to escalate into ISF4 (Intensive Support Framework Level 4) and therefore relocate PGDiT (Post Graduate Doctors in Training) to other specialities or the BRI (Bristol Royal Infirmary) site. In summary, 10 Foundation year 1 (F1), 3 Foundation year 2 (F2) and 2 Internal Medicine Training (IMT) posts were relocated to the Bristol Royal Infirmary site or into alternative specialities at WGH.
Following the visit on 29/3/23 most posts were approved to return to their original specialities from August 2023. Two F1 posts remained at the Bristol Royal Infirmary site, and one remained relocated in Intensive Care Medicine at Weston General Hospital. One F2 post remained relocated in gastroenterology at WGH. One IMT post will now permanently be relocated in rheumatology at WGH.
At the last visit in November 2023 the review found evidence of further progress, but a further visit was recommended.
Data from the GMC National Training Survey and NHS England WT&E SW Quality Panels have continued to show poor feedback from PGDiT in medical programmes and specialities.
Who we met with
Learners
- Foundation 1 and 2 grade postgraduate doctors in training (PGDiT)
- Internal Medicine Training years 1-3 PGDiT
Educators
- Consultants from the medical departments and College Tutor
Education team
- Director of Medical Education
- Site Medical Director for WGH
- Chief Medical Officer
Review Panel
Education Quality Review Lead
- Ilana Langdon – Associate Dean for Quality
Specialty Expert
- Carolyn Mackinlay – Head of School Medicine
External Specialty Expert
- Clare Van Hamel – Head of School Foundation
NHS England Lay Representative
- Jennifer Hepworth
Supporting roles
- Geoff Smith – Regional Postgraduate Dean
- Lucy Llewellyn – GMC Quality Manager
Review findings
Domain 1: Learning environment and culture
A PGDiT (postgraduate doctor in training) had negative feedback comments within their Placement Supervision Group Team Assessment of Behaviour (PSG TAB) for asking about how to manage complex patients. The PGDiT present said that asking questions about patient care was not welcomed by some seniors.
The panel was told that handover is dependent on the middle grade doctor leading the handover. It can be variable in terms of quality of clinical/educational input, but the situation was improved compared to the previous visit’s findings of chaotic and unsafe handover.
Domain 2: Educational governance and commitment to quality
PGDiT (postgraduate doctors in training) present said that the induction they received was generally reasonable. The panel noted that IT access in induction is still not consistent for PGDiT.
Regarding the allocation of clinical and educational supervisors (CS/ES), nearly all allocations and meetings between PGDiT and supervisor occurred in a timely fashion, with the exception of one who was unable to meet their CS for three months. When the meeting did take place it only lasted a few minutes and was therefore unsatisfactory in depth and assessing learning needs. The PGDiT in question said that in contrast their ES was very helpful and thorough.
Foundation 1 (F1) PGDiT raised that they were still expected by some colleagues in the trust to complete “ReSPECT” (Recommended Summary Plan for Emergency Care and Treatment) forms, which relate to treatment escalation and care, despite NHS policy that doctors at this level are not sufficiently experienced to complete these. Some nurses haven’t been made aware of the policy, and PGDiT told the panel that this has only recently been addressed by the trust. However, teaching on how to complete ReSPECT forms, treatment escalation and end of life care is good.
Domain 3: Developing and supporting learners
Appropriate supervision for PGDiT was stated to be very variable. The panel heard that it was good in AMU (the acute medicine unit), though supervisory presence on the wards or SDEC (Same Day Emergency Care Unit) is not regularly at a satisfactory level. The panel heard that most areas are understaffed, with the exception of the AMU which is reported as possibly overstaffed by the PGDiT in this visit.
An IMT (Internal Medicine Training) Year 3 PGDiT is given a caseload of F1 (Foundation Year 1) level work to do, so they are unable to assist their more junior colleagues with supervision, queries and other support as would be expected in a normal team structure. This does not give appropriate learning opportunities, nor advance the IMT3 doctor’s training and is a waste of the resources of having an IMT3 on the unit.
PGDiT present said that they would like to be involved in quality improvement within the hospital and the panel heard interest in projects relating to WGH clinical risks, radiation, length of stay, failed discharge and patient/relatives’ communication. However, their participation in QI projects is not facilitated.
Domain 4: Developing and supporting supervisors
The panel noted that certain consultants continue to offer additional time to teach and support their PGDiT, often coming in outside of their normal hours to do this, according to the PGDiT present.
In our meeting with the education team, it was confirmed that job planning for clinical and educational supervision is still inconsistent and that the proportion of consultant staff currently accredited and delivering supervision is unchanged. The senior management team informed the panel that job planning is still being worked on. There does not appear to have been any progress since the last visit.
The proportion of senior staffing at the WGH site delivered by locums is much higher than at the Bristol Royal Infirmary site. The level of adequate clinical and educational supervision is correspondingly inconsistent.
Domain 5: Delivering curricula and assessments
Regarding Supervised Learning Events (SLE) / Work-based assessments (WBAs), the PGDiT present said that access to Acute Care Assessment Tool (ACAT) SLE was better than a few years ago, but still reliant on a consultant coming in early at 6am.
Clinic opportunities remain restricted, even if PGDiT have the time to attend. However, the panel heard that Rheumatology has excellent clinic opportunities.
Foundation teaching is often cancelled, and some PGDiT present said that it was often of a poor quality. This was a notable area of deterioration compared to our last visit. Internal Medicine Training (IMT) teaching is only at Bristol, so this is generally impossible for WGH- based PGDiT to attend face to face. They feel disadvantaged by joining the teaching online where others are face to face.
Domain 6: Developing a sustainable workforce
Currently, there is no Chief Registrar in medicine, only in surgery. Whilst the Chief Registrar in surgery is highly regarded by the PGDiT present, the PGDiT and the panel felt that it would be beneficial to have a Chief Registrar in Medicine as well, to contribute to the significant work involved in improving the training environment within medicine at WGH.
Friends and family questions
The panel also heard that PGDiT working at WGH would not wish their friends or family to be treated at the hospital in most circumstances, but that this would depend upon the nature of the admission. None of the doctors within medicine would recommend their post (a follow-up questionnaire circulated by the PGDiT to gain wider feedback to this question confirmed this).
Areas for improvement
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| Inconsistent learning agreement meetings with a lack of educational governance/oversight | PGME team to monitor and ensure compliance in delivering timely, appropriate learning agreements and assure NHSE that this has been carried out for PGDiT. Review date: 01/11/2024 | 3.4 |
| F1 doctors recently still expected to complete ReSPECT forms, with recent trust intervention | Ensure all staff aware of policy and monitor compliance Review date: 01/09/2024 | 1.5,1.6 |
| Supervision of Foundation doctors: There is evidence of a lack of support for clinical decision making and unrealistic expectations of FY1 doctors by some staff. | Clear evidence of communication with both locum and substantive staff about the support required for FY1 doctors within the clinical and work environment Review date: 01/08/2024 | 3.11 1.5 |
| Local teaching for F1/2 – often cancelled or poor quality IM only at Bristol | Ensure adequate teaching programme access for all grades, and share the plans for ensuring access for all PGDiT to planned teaching with NHSE Review date: 01/11/2024 | 1.1 |
| PGDiT would like to be involved in QI projects to improve service delivery at WGH and to meet the curriculum requirements for sign off | Coordinate PGDiT input into service redesign and QI Review date: 01/02/2025 | 1.9 |
| There is inconsistent educational governance across the sites of the trust | Supply a short-, medium- and long-term plan to ensure consistent educational governance across UHBW/WGH. Review date:01/02/2025 | |
| Clinical role and level of entrustment of IMT doctors: reports that IMT level doctors were expected to provide very basic clinical roles with little or no autonomy | Review of the IMT roles and working plan, to balance autonomous decision making and clinical supervision appropriately to deliver and safe and effective learning environment. Review date: 01/02/2025 | |
| Inconsistent job planning and payment for CS/ES, low proportion of consultants as supervisors | Ensure consistent job planning and payment, active plan to increase supervisors in line with Educator Workforce Strategy. Review date: 01/02/2025 | |
| Overarching balance of the numbers of substantive staff between the provider sites to ensure a robust clinical and training environment across the Trusts | NHSE WTE Quality team and UHBW to ensure this is raised at the BNSSG System Quality Group and support the development of an action plan to increase cross site working, and substantive recruitment at the WGH site. Review date: 01/11/2024 |
Recommendations
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
| Induction remains inconsistent Action: Ensure consistent induction experience, including HR process and IT access Review date: 01/02/2025 | 3.9 |
Follow-up visit requirements
Follow-up visit required: Yes
Follow-up visit timescale: June 2025
Report approval
Report completed by: Ilana Langdon, Associate Dean for Quality
Review lead: Ilana Langdon
Date signed: 11 September 2024
NHS England authorised signature: Dr Geoff Smith, Regional Postgraduate Dean, SW
Publication reference: PRN01548