Executive summary

No Foundation or Core Postgraduate Doctors in Training (PGDiT) were present from general surgery therefore no further feedback was received to provide assurances that education and training has improved in general surgery since our last visit. 

Overall, the feedback from Foundation and Core PGDiT in plastic surgery and ear, nose and throat (ENT) was good, and they would recommend their training post. Foundation PGDiT spoke positively about the working culture with friendly and approachable seniors who are keen to teach. It was reported that there is a culture of continuous learning, where giving and receiving constructive feedback is encouraged and is routine practice. Both departments were highly praised for the senior support and supervision provided to both foundation and core PGDiT.

Concerns previously raised regarding ENT referrals during out of hours and weekends has improved for Foundation year 2 doctors (F2s). It was reported that there is now a twilight doctor in the evenings and an extra doctor at weekends which has significantly helped with workload. Colleagues in the department have been instrumental in ensuring inappropriate referrals from the emergency department are monitored and an internal audit was carried out to assist with this. The volume of referrals from the emergency department was no longer being reported as causing significant pressures or considered a problem for Core PGDiT, however, it was acknowledged that referrals will remain high.

There were no concerns with induction and the opportunity to shadow others on call during their first two weeks in post was described as ‘good’ but unfortunately not all had the opportunity to do this.

Foundation and core PGDiT in ENT and plastic surgery confirmed that they have a shared doctor’s office and described it as overcrowded.

In summary, the areas highlighted to the panel that need addressing are: 

• ENT – Shadowing during the first two weeks of on calls for foundation and Core PGDiT. It was reported that this is not happening for all as outlined in the improvement plan.

Based on the review findings, we will be recommending that the ISF category remains as an ISF category 1. An updated trust improvement plan will be required against the outstanding mandatory requirements outlined in the previous report for general surgery and new mandatory requirements outlined in this report.

Who we met with

Learners

• Foundation and Core PGDiT in ENT and Plastic Surgery

Educators

• Plastic surgery and ENT educators

Senior Team

• Medical Education Team

Review panel

• Dr Rachel Parry, Head of School – Foundation LNR
• Mr Nicholas Watson, Higher Surgery Training Programme Director
• Kerry Olley, Quality Deputy Manager
• Sinead Cobb, Quality Administrator

Review overview 

Background to the review

The results for the national education and training survey (NETS) 2022 showed multiple areas where responses were below the national average for foundation surgery postgraduate doctors in training (PGDiT) at UHL based at the LRI.  Concerns were also raised to the foundation Head of School regarding the Ear, Nose and Throat (ENT) and plastic surgery rotation.

To better understand the learning environment and experience, a learner/educator meeting was held on 28 September 2023. In summary, the areas highlighted to the panel that needed addressing were: 

ENT & Plastic surgery 

• ENT (out of hours and weekends), workload and facilities.

General Surgery 

• Induction, teaching, culture and facilities

Based on the review findings, the item remained as an Intensive Support Framework (ISF) category 1. A follow up visit to review progress was organised for June 2024.

Review findings

Support, supervision, and rota

Foundation and core PGDiT in plastic surgery and ENT reported that the senior support they receive is ‘good’. They all reported that senior colleagues are helpful, and they receive the appropriate level of support needed for their training. 

The on-call rota in ENT is still being reported as having a high number of emergency department referrals but the support of having an additional twilight doctor and an extra doctor at the weekends on the rota has helped. It was however reported to be quite a steep learning curve as an F2 doctor, but no further reports were made of being the first point of contact for ENT referrals and being asked to act outside of their competencies. During the educator session it was reported that following an internal audit of the emergency department referrals, the department are now creating pathways to help manage referrals appropriately. The ENT and plastic surgery departments are unable to fully influence the emergency department processes, however they have put solutions in place to reduce the impact of the referrals on PGDiT.

The current trust improvement plan reports that F2s have a shadowing opportunity for the first two weeks in ENT whilst they are on call. This was described as really good by the foundation doctors who received shadowing, but it was reported that not everyone had this opportunity. Foundation doctors in plastic surgery also reported that shadowing took place however there was a delay (3 – 4 weeks into post) and didn’t get this until after their first on call shift and although it was described as ‘really good’ they would have preferred to have had this as soon as they started in post.

Core PGDiT also reported that some of them went straight onto the on-call rota without shadowing, and that shadowing was provided for some but not all.

Induction

Overall, inductions continue to be described as good and appropriate for their level of training. Core and Foundation PGDiT in plastic surgery and ENT all reported that they had received an induction and felt prepared for the post. Foundation doctors in plastic surgery highly praised the practical aspect of the induction.

In ENT it was reported that there was a lot of information to take in at once, although it was acknowledged that the handbooks PGDiT can refer to are good.  

Core PGDiT across both departments reported that the induction was thorough, they had protected time to attend, and it was described as one of the better inductions that they have been to. It was also reported that there were handbooks available to refer to plus they received presentations, and all relevant guidelines.

The plastic surgery induction was reported by core PGDiT as being carried out a couple of days after they started in post which was a good, relevant induction, however they added it would have been better on day one.

Workload 

Foundation year one (F1) doctors in plastic surgery reported that weekend on calls predominantly provide ward cover but they also see patients in the emergency department. The workload was reported as manageable and suitable for their level of training with good levels of senior support. 

The ENT workload was also reported as manageable by foundation doctors, and they all manage to take their breaks and the support available to them is good.

Core PGDiT reported that the workload is still high in ENT. It was reported however that they now have an additional twilight doctor who starts at 14:00 until midnight which was described as helpful. It was reported that most of the referrals from the emergency department are appropriate and the more serious referrals are being sent straight to the higher PGDiT. During the educator session it was reported that discussions are ongoing regarding consultants being released for half a day to support with the emergency department referrals to ENT. It was noted that if they received this support, it would have a positive impact.

Teaching

It was reported that ENT teaching takes place once a week which is working well. Senior colleagues are fully aware of the sessions and encourage them all to go. It was also reported that PGDiT from plastic surgery can also attend, and they are made to feel very welcome which was highly praised. Compliments were made about cross working across plastic surgery and ENT with regards to training. They all welcomed ENT into plastics training and vice versa.

The ENT foundation year 2 doctors reported that they have missed some departmental teaching due to on call commitments. During the educator session it was reported that work is ongoing to make improvements to this and with the increase in F2s from august it will decrease the volume of on call commitments. They have also tried to put on additional half day sessions twice a month to increase attendance opportunities. 

Foundation year one doctors in plastics reported that they have good exposure to training opportunities with designated theatre and clinic time and regard it as one of the better rotations they have been on.

Core PGDiT in the plastics department reported that there is departmental teaching every Tuesday which is overseen by the consultant and there are ample opportunities to complete workplace-based assessments.

Facilities

Foundation and core PGDiT reported that they share a room with plastic surgery and ENT, which can be overcrowded. At weekends the office space is reported as manageable although it can be busy during the week. 

It was reported that there are provisions in place for locking away possessions but not for all and some reported having to carry their bags around with them for the day. There are no lockers available for core trainees in theatre yet, but it was reported that they are on a waiting list.

Culture

In ENT foundation doctors spoke positively about the working culture and it was described as the best team they have worked in this year. It was reported that they never feel they are hassling people, and everyone is approachable. Foundation doctors reported that they feel comfortable calling anyone and if they ever raise anything it is an open conversation, and the issue is dealt with. Core PGDiT also reported that they can raise any concerns they might have with senior colleagues comfortably.

Similar positive feedback was also received from plastic surgery foundation and core PGDiT. All the seniors are approachable, keen to teach, friendly, and supportive. The departmental culture is positive and collaborative.

Requirements

Requirements are set where NHS England have found that standards are not being met; a requirement is an action that is compulsory. These are categorised between Mandatory Requirements that NHS England will require an update against as part of the collective findings and Immediate Mandatory Requirements that given the severity, will require an urgent response.  

Mandatory requirements

Areas of improvement

Areas of improvement are where progress has been noted against previously identified areas of concern.  

Report approval

Report completed by: Kerry Olley, Quality Deputy Manager
Review lead: Rachel Parry, Head of school for Foundation
Date approved by review lead: 10 July 2024

NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean
Date authorised: 25 July 2024

Final report submitted to organisation: 4 September 2024