Executive summary

NHS England South West Workforce Training and Education carried out a quality review as part of an ongoing process with the department and the Trust, with the last review in November 2023.  That review found recent improvement, but it was too soon to assess whether it was sustainable.

The improvement in the educational and clinical opportunities for the Core Surgical Trainees (CST) in Trauma and Orthopaedic Surgery (T&O) at Bristol Royal Infirmary (BRI) site of UHBW has been sustained, and no longer presents concern.

Supervision, induction and training for foundation trainees has continued to improve. The well-being programme and buddying system have excellent feedback.  Continued funding for this programme has been agreed.

The planned multiprofessional recruitment, including Clinical Educational Fellows, “Silver Trauma” orthogeriatric fellows and Physician Associates, is now complete and embedded.  It has paid dividends in allowing access to learning opportunities and reliable study leave absence.

Consultant presence on the ward for face-to-face review of patients and providing bedside clinical teaching and assessment is now reliable.  Local teaching by T&O registrars and consultants in the trauma meeting and using work-based assessments is very good. 

Foundation Year 1 doctors would prefer to do their on-call duties in T&O rather than general surgery, as is currently the case, due to improved learning in T&O and for continuity.

There are no further actions, and the panel’s recommendation is to return this setting to routine monitoring.

Review overview

Background to the review

The purpose of this visit was to review the education and training environment for trauma and orthopaedics (T&O) doctors in training at Bristol Royal Infirmary (BRI). The visit sought to follow up on the required actions that were mandated by HEE at the previous triggered visits in 2021 and 2022, specifically regarding concerns raised around insufficient clinical supervision of foundation doctors.

Who we met with

Learners

• Foundation 1 and 2 grade postgraduate doctors in training (PGDiT)
• Clinical Teaching and Education Fellow

Educators

• RCS College Tutor, who is also a consultant in the Trauma and Orthopaedics department.

Education team

• Director of Medical Education
• Medical Education Manager

Review panel

Education Quality Review Lead   

• Ilana Langdon, Associate Dean for Quality

Specialty Expert     

• Clare Van Hamel, Head of School for Foundation

NHS England Lay Representative

• Jennifer Hepworth

Review findings

Domain 1: Learning Environment and Culture 

PGDiT present said that concerns about staffing levels have improved, and they now have more frequent and very good learning opportunities. PGDiT are encouraged to go to clinic or theatre whenever possible, but this is not timetabled. Some foundation doctors would prefer this, but not all.  PGDiT are encouraged to attend the morning trauma meeting, which affords excellent learning.

PGDiT said that the regular 2pm consultant ward round meeting with the consultant team of the day now almost always occurs. If something cannot wait, the PGDiT will speak to the on call team, who are easily accessible. Other consultants also come to the ward to see their own patients as needed.

The designated “silver trauma” ward (604) has very good orthogeriatric cover.  On ward 602, the orthogeriatric consultant’s presence is variable. Some of the orthogeriatric fellows contribute less to team-working with the T&O PGDiT than others, and it was felt that this could be more consistent.  According to trust protocol, all orthogeriatric patients should be transferred to 604, as promptly as possible.

Domain 2: Educational Governance and Commitment to Quality 

The panel heard that the departmental induction was brief but of good quality and complemented the trust online induction. All PGDiT knew who their supervisors were on starting the post and met with them in a timely manner. PGDiT present stated that this placement was better than others through which they have rotated so far in terms of opportunities for learning, with educational opportunities made available through the day, including over lunchtimes.

Some PGDiT were concerned that funding has been discontinued for an educational and well-being/support initiative – Breakfast Club. The feedback for this from PGDiT was very good, both direct feedback in this meeting, and formal feedback evaluation from the Deputy DME for Quality.  The Educational Lead and Divisional Director confirmed in the feedback meeting that funding is now to continue.

PGDiT present said that they would be happy for their friends and family to be treated in the BRI T&O department, or to recommend their post to fellow PGDiT.

Domain 3: Developing and Supporting Learners 

F2s present said that they would benefit from having the F1 PGDiT on call with them. Often the F2s have multiple tasks that need to be done at once. These are well within the ability of an F1 and would also provide more teaching opportunities for F1s.

The registrars were said to be very welcoming and encouraging to PGDiT being involved in quality improvement projects.

Domain 4: Developing and Supporting Supervisors 

The panel heard that the department feels more sustainable, and less reliant on the efforts of a single consultant or a handful of consultants to keep everything running and on track.

Domain 5: Delivering Curricula and Assessments   

PGDiT present said that it is fairly easy to complete Supervised Learning Events (SLEs), with registrars described as very forthcoming and proactive.

Those present also praised the buddying system, whereby Foundation 1 PGDiT (F1s) and Foundation 2 PGDiT (F2s) are supported and guided by the Clinical Teaching Fellows and Core Surgical Trainees (CST) ward rounds, in the ward itself, discussing patient plans and going through X-rays.

The panel heard that generally Foundation Year 1 PGDiT felt that they would benefit from more specific experience with T&O cases and that being on call for T&O instead of General Surgery would be preferable. For many PGDiT present, this was their only T&O rotation in Foundation training.

Domain 6: Developing a Sustainable Workforce   

PGDiT present praised the physician associates (PAs) alongside whom they work, as they do a lot of paperwork, administrative tasks and provision of general support for the PGDiT.  They are becoming increasingly experienced in T&O, and thereby provide continuity and institutional memory to rotating doctors.  There were no concerns from the doctors that PA training or development were impacting in a negative way on their training – the PA workforce is improving their educational opportunities.

PGDiT said they would be very happy to continue working in T&O at the BRI. The team is supportive and welcoming, they are encouraged to attend theatre and one PGDiT present said that it was “the best team [they’d] had within F1 and F2 training”.

Areas that are working well

Good practice is used as a phrase to incorporate educational or patient care initiatives that, in the view of the Quality Review Team, deliver quality above and beyond the standards set out in the Education Quality Framework.  Examples of good practice may be worthy of wider dissemination.

Clinical Teaching Fellows help with local teaching and the buddy system is working very well.

The Breakfast Club provides excellent wellbeing and support.

Physician Associates within the team are praised for supporting education; they improve access to educational opportunities and give continuity across rotations.

Areas for improvement

Recommendations

Recommendations are not mandatory but intended to be helpful, and they would not be expected to be included within any requirements for the provider in terms of action plans or timeframe.  It may however be useful to raise them at any future reviews or conversations with the provider in terms of evaluating whether they have resulted in any beneficial outcome.

Report approval

Report completed by: Ilana Langdon, Associate Dean for Quality
Review lead: Ilana Langdon
Date signed: 9 August 2024

NHS England authorised signature: Dr Geoff Smith, Regional Postgraduate Dean, SW
Date signed: 16 August 2024

Final report submitted to organisation: 1 October 2024