Executive summary
Ear, Nose and Throat (ENT) and plastic surgery was well represented and overall, the feedback from resident doctors in ENT and plastics regarding their education and training experience was positive. There was limited attendance from general surgery, however, the trust has advised that some resident doctors were not aware of the visit. Due to the limited attendance, we have been unable to gain the required assurances regarding foundation training within general surgery.
Inductions were described as good and all resident doctors reported receiving a comprehensive induction.
The opportunity to shadow others on-call during the first two weeks was generally described as positive. However, not all resident doctors had this opportunity despite this being an action on the current improvement plan. The trust stated that they would explore the possibility of making it a mandatory requirement. Additionally, there was a request from resident doctors for more information about the on-call process, especially given the cross-cover support provided to ENT and plastics. Resident doctors in ENT reported that they lack some of the knowledge, skills and experience required to cover plastic surgery on calls, and they feel particularly unprepared to deal with hand trauma.
Resident doctors in general surgery reported that rota gaps, especially during night shifts, often go unfilled, making the workload particularly challenging.
In summary, the areas highlighted to the panel that need addressing are:
- Culture – in general surgery it was reported that there have been occasional concerns raised by consultants regarding the suitability of overnight admissions. Collaboration with the ED department also remains a challenge.
- Workload – Resident doctors in general surgery reported that gaps, especially during night shifts, often go unfilled, making the workload particularly challenging.
We are satisfied with the training experience for foundation doctors within ENT and plastic surgery and the current risk item will be closed for these specialty areas. We do not currently have assurances about the training experience for foundation doctors in general surgery therefore this item will remain as an Intensive Support Framework (ISF) category 1 specifically for foundation training in general surgery.
Review overview
The results for the National Education and Training Survey (NETS) in 2022 showed multiple areas where responses were below the national average for foundation surgery resident doctors at UHL based at the LRI. Concerns were also raised to the Foundation Head of School regarding the ENT and plastic surgery rotation.
To better understand the learning environment and experience, a learner educator meeting was held on 28 September 2023. There were multiple mandatory requirements resulting from this visit and an improvement plan was put in place.
A follow up visit to review progress was organised for June 2024. At this visit no foundation or core resident doctors were present from general surgery. The feedback from foundation and core resident doctors in plastic surgery and ENT was good, and they would recommend their training post. Foundation resident doctors spoke positively about the working culture describing friendly and approachable seniors who are keen to teach.
An area that still needed addressing was the shadowing opportunity for ENT resident doctors during the first two weeks of on-calls for foundation and core resident doctors. It was reported that this is not happening for all as outlined in the improvement plan.
A follow up visit was organised for March 2025 to review progress and gather feedback from resident doctors in general surgery.
Who we met with
Learners
- Foundation and core resident doctors in surgery specialities – Plastics, ENT and General Surgery
Educators
- Clinical and Educational Supervisors
- Service Leads
- College Tutor
Education team
- Deputy Director of Medical Education
- Education Centre Manager
- Education Lead for ENT & Plastics
- Clinical Director for General Surgery
Review Panel
- Rachel Parry, Foundation Head of School, LNR
- Mr Nicholas Watson, General Surgery Training Programme Director Kerry Olley, Quality Deputy Manager
Review findings
Induction and shadowing
All resident doctors reported a comprehensive induction across all specialties. The induction for plastic surgery was described as thorough, covering both clinical and administrative components. They confirmed that they also received an ENT induction.
The general surgery induction was also reported as comprehensive, with resident doctors being provided access to numerous useful documents. All new resident doctors were given protected time to attend, ensuring full participation. However, resident doctors expressed a desire for more information regarding the on-call process, particularly because they provide cross cover support to ENT and plastics.
Some concerns were raised that the plastic surgery induction did not adequately prepare resident doctors for managing hand trauma. Additionally, not all had the opportunity to shadow before starting on-call duties. This issue was discussed during the educator session, where it was clarified that shadowing opportunities are presented as an option during induction. The trust is now considering whether to make shadowing a mandatory requirement for all new resident doctors.
Those who did have the shadowing opportunity and were paired with an experienced colleague reported feeling well supported and prepared for the cross cover on-calls.
Regarding the Nervecentre system at night, resident doctors reported that they were not aware of formal training for the system and do not recall being shown this at induction. However, they were able to learn the system independently and found it to be highly effective. It was reported as being a good handover system and better than having multiple verbal handovers.
Culture
The culture within the plastics and ENT teams is reported to be very positive. However, collaboration with the emergency department remains a challenge. Due to the intensity of workload within ED, resident doctors often feel pressured to see patients quickly, with frequent follow-up calls being received from ED. At times, it was reported that this can feel ‘pushy’, with some foundation doctors describing the experience as unpleasant. Some shared that they had even felt bullied by the department. This issue has been raised within the team, and one of the consultants has been actively advocating for improvement. The handling of inappropriate referrals by ED has also been a topic of discussion. When discussed during the educator session, the team acknowledged that this is a known issue and affects all levels of staff in the department.
Senior doctors in ENT are reported to be supportive, particularly when resident doctors admit patients who may not meet admission criteria during on-call. They also reported that Ward 9 staff, including nurses, were particularly helpful.
In general surgery it was reported that there have been occasional concerns raised by consultants regarding the suitability of overnight admissions made by resident doctors. When asked if resident doctors feel confident in dealing with those challenges from consultants, some were more confident than others.
Resident doctors reported feeling distressed by comments made at the general surgery induction that the rotation would be challenging, and that it was expected/normalised behaviour that ‘they would cry’.
Teaching
Resident doctors in plastics and ENT reported that although they achieve portfolio requirements, they would welcome more practical experience in theatres or clinics. They reported that there has been a significant increase in patient numbers therefore they are the first ones to be pulled from theatre or clinic time to support managing patients on the wards. In ENT and plastics, it was reported that educators are responsive to suggestions resident doctors make to give them additional exposure to training opportunities and are keen to teach.
ENT resident doctors reported that they are not aware of any plastics training opportunities beyond induction. Resident doctors in ENT reported that they lack knowledge, skills and experience in plastics, and they feel particularly unprepared to deal with hand trauma. This was discussed during the educator session, where it was shared that a teaching programme is in place which is protected time on the rota for plastics resident doctors. The educators reported that they will liaise with the administrator in ENT to ensure it is also visible on the ENT rota so all resident doctors are aware of the training and can attend.
In general surgery it was reported that senior doctors are meant to take foundation resident doctors phones so they can attend core foundation teaching on Wednesdays. Even though sometimes they are hesitant to take the phones, the situation is improving. It was reported that the Friday, departmental teaching is predominantly peer to peer and resident doctors would prefer some teaching with consultants.
Workload
Resident doctors in general surgery reported that gaps, especially during night shifts, often go unfilled, making the workload particularly challenging. They reported that staff absences due to sickness or pre-planned annual leave are not always covered.
Mandatory requirements
| Review findings | Required action | Reference number and domain(s) and standard(s) |
|---|---|---|
| Culture – existing mandatory requirement In general surgery it was reported that there have been occasional concerns raised by consultants regarding the suitability of overnight admissions. Some resident doctors feel comfortable dealing with those challenges, but others have expressed a lack of confidence in doing so. Collaboration with the ED department is a challenge. At times, it was reported that this can feel pushy, and some foundation doctors have described the experience as unpleasant, with some even feeling bullied by the department. | The organisational culture should be one in which all staff are treated fairly, with equity, consistency, dignity and respect. The trust needs to continue to review culture within the departments. | 1.7 |
| Workload Resident doctors in general surgery reported that gaps, especially during night shifts, often go unfilled, making the workload particularly challenging. They reported that staff absences due to sickness or pre-planned annual leave are not always covered. | The trust to review current approach to managing rota gaps. This should involve engagement with resident doctors. | 1.5 |
Recommendations
Recommendations are not mandatory but intended to be helpful as a suggested course of action. An improvement plan is not required for these areas.
| Related education quality framework domain(s) and standard(s) | Recommendation |
|---|---|
| Induction (shadowing) – existing mandatory requirement | Not all resident doctors had the opportunity to shadow before starting on-call duties as per the current improvement plan. The trust to consider making shadowing a mandatory requirement for on call duties. |
Report approval
Report completed by: Kerry Olley, Quality Deputy Manager
Review lead: Rachel Parry, Head of school for Foundation
Date approved by review lead: 2 April 2025
NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean
Date authorised: 15 May 2025
Final report submitted to organisation: 2 June 2025