Executive summary

Resident doctors identified a range of significant concerns regarding training delivery within the plastic surgery department at Royal Stoke University Hospital, alongside a few positive aspects of the training environment in specific sub-specialty firms.

Areas identified as working well include:

• The consultant body in breast and skin sub-specialty teams were described as approachable and supportive, with several consultants specifically commended for their commitment to teaching.
• Some sub-specialty teams, particularly breast and skin, were identified as providing better training opportunities.

Significant concerns requiring attention include:

• Inadequate clinical supervision arrangements for local anaesthetic lists and the Central Treatment Suite (CTS) / dressings clinic.
• Limited exposure to complex procedures, with resident doctors reporting a decline in operative training opportunities in the last 2 years.
• Significant cultural issues and interpersonal dynamics affecting the learning environment in some sub-specialty teams.
• Systematic prioritisation of service provision over training opportunities, with evidence of training being regularly compromised to meet service needs.
• Challenges with cross-site working affecting training opportunities and creating additional burdens for resident doctors.
• Reports that a significant proportion of resident doctors’ time spent performing simple procedures with limited educational value rather than gaining appropriate curriculum experience.
• Reports that locally employed doctors feel unable to raise concerns due to job security fears, creating a challenging learning environment.

The department faces considerable service pressures. While this creates challenges in balancing service provision with training opportunities, trainers and the education team acknowledged there is a need for substantial improvement in how these pressures are managed to protect training.

Based on the significant concerns identified regarding professional behaviours, inadequate supervision, and failure to prioritise training over service provision, the panel will be recommending this item is increased from an Intensive Support Framework (ISF) category 1 to ISF category 3. A Trust improvement plan will be required against the mandatory requirements outlined in this report, with regular progress updates and close monitoring of implementation. 

Review overview

Background to the review

In 2021, the department had demonstrated high resident doctor satisfaction. The 2023 NETS survey results showed a deterioration in the training environment with overall experience and induction domains falling to negative outliers. The 2024 GMC National Training Survey showed a further significant decline in resident doctor experience with 5 domains in the lower quartile and seven returned as negative outliers. These resident doctor survey results prompted this review to understand the challenges and to support improvement in the training environment.

Who we met with

Learners

• Resident doctors in plastic surgery
• Resident doctors in core surgical training
• Locally employed doctors

Educators

• Director of Medical Education
• College Tutor
• Consultant plastic surgeons

Education team

• Director of Medical Education
• College Tutor
• Medical Education Manager

Review panel

Education Quality Review Lead   

• Andy Garnham, Head of School, Postgraduate School of Surgery

Specialty Expert     

• Elizabeth Chipp, Training Programme Director and Chair, Plastic Surgery Training Committee

External Specialty Expert    

• Duncan Bowyer, Quality Lead, Postgraduate School of Surgery

NHSE Education Quality Representative(s)      

• Kalpesh Thankey, Quality Deputy Manager 

Review findings

Learning environment and training opportunities

Resident doctors reported varied experiences across different sub-specialty teams within the plastic surgery department. In some areas, particularly the skin and breast firms, resident doctors identified consultants who provide good teaching opportunities. Resident doctors reported that in other firms, the consultant body has outdated expectations of resident doctors in direct conflict with current curriculum and training requirements.

Resident doctors reported a general decline in operative training opportunities over the past two years. They described receiving substantial theoretical discussion and teaching but limited hands-on training opportunities.

Resident doctors reported that during general anaesthetic major cases, they often find themselves retracting or assisting rather than performing procedures. In some sub-specialty areas, resident doctors reported having no opportunity for hands-on surgery throughout their rotation.

In local anaesthetic lists, resident doctors reported performing a high volume of skin excisions and direct closure procedures. They explained that opportunities to perform local flaps or grafts are limited due to the volume of simpler cases requiring completion.

Trainers acknowledged the high volume of skin cancer work, noting they receive approximately 10,000 referrals annually. Trainers reported that the service pressure to meet two-week wait targets affects their ability to provide operative training opportunities.

Departmental culture

Resident doctors reported significant variation in the educational culture across different sub-specialty teams. While some consultants were praised for their teaching commitment, serious concerns were raised about the cultural environment in certain areas.

Resident doctors reported feeling unappreciated and unsupported in certain sub-specialty teams. Resident doctors mentioned experiencing unsatisfactory behaviours from more than one unnamed senior consultant in the department, describing working in some firms as frustrating and stressful.

Locally employed doctors reported feeling unable to raise concerns due to job security fears.

Clinical supervision

Resident doctors reported variable supervision arrangements across different firms. While some areas provide consistent supervision, others present significant challenges with some senior supervisors being described as uncooperative and providing no educational support.

Resident doctors reported performing numerous local anaesthetic skin excisions where supervision was available but not directly present in theatre (unscrubbed supervision).

For local anaesthetic lists, resident doctors described two types of arrangements: some with a named consultant, and others where they rely on consultants being available in the office if needed. They noted that while help is generally available when requested, there is no formal supervision structure or assigned consultant for many lists.

In addition, resident doctors expressed concern about the limited opportunity for intra and interoperative guidance from supervisors about margin adequacy and pressure to complete cases promptly due to heavy lists.

Trainers reported that their offices are located close to clinical areas, being approximately two minutes from where resident doctors work. They stated that there is usually someone available in the office and the on-call consultant is typically, but not always, in the hospital. Whilst unscrubbed supervision is reasonable for these cases, the supervision arrangements need to be formalised, clear, and accessible when needed, so that resident doctors can discuss cases in a timely manner.

The education team recognised that greater formal supervision arrangements would benefit junior doctors, particularly those new to plastic surgery, acknowledging the need for all lists to be supervised by a named consultant, even if the supervision is remote.

Rota management and service provision

Significant challenges were raised regarding the rota system. Resident doctors reported being moved at short notice from valuable training opportunities at Stoke Hospital to cover service provision local anaesthetic lists at County Hospital, resulting in significant travel time (approximately 35 minutes) and inefficient service delivery with only a portion of scheduled patients being seen. This results in a significant loss of educational experience for the affected resident doctors. Resident doctors reported that they are frequently contacted directly by members of the operations team requesting short notice changes to planned commitments without such requests going via the consultant body. Resident doctors do not feel confident to decline such requests even when they impact on their training opportunities.

Resident doctors reported that departmental teaching is led by registrars but is not protected time, meaning many resident doctors cannot attend due to clinical commitments. When attendance is poor or sessions experience difficulties, resident doctors described being held responsible by trainers rather than addressing the systemic scheduling issues.

Trainers acknowledged the pressure from the operations team to cover service provision local anaesthetic operating lists, reporting that training commitments are sometimes cancelled when service pressures arise. They described trying to balance service provision with training opportunities but noted that operational management in the department places strong emphasis on service delivery. The education team reported that the rota coordinator will be taking a more active role in managing the rota, this will include consultant involvement to ensure better protection of training opportunities.

Central treatment suite (CTS) / dressing clinic

Resident doctors reported significant challenges with the CTS / dressing clinic structure and organisation. Resident doctors in core surgical training reported being required to cover the clinic multiple times per week, sometimes for two or three days in the same week. They described clinics regularly overrunning from morning into afternoon sessions due to an open booking system that allows other departments, including orthopaedics, maxillofacial and emergency department (ED), to directly book patients into the clinic. Resident doctors reported being required to see patients who are attending for their first review after ED, necessitating full histories and assessments.

Trainers reported that they disagree with the current clinic structure, where doctors are required to see every patient. Trainers stated they are trying to establish a nurse-led clinic model but face resistance from the operational management team.

The education team reported that nurses are not empowered to make decisions about normal wounds, requiring doctor review for all cases, including routine wound checks, The education team acknowledged the current mandate requiring doctor presence for all clinic patients, even routine cases, as problematic. While presented as providing optimal patient experience, this arrangement significantly hindered access to other valuable training opportunities across the department.

Cross-site working and accommodation

Resident doctors reported significant challenges with cross-site working and described being moved from training opportunities at Stoke Hospital at short notice on the day to cover a half-day local anaesthetic service list at County Hospital, resulting in a 35-minute travel time and only a partial number of scheduled patients being seen. When this was raised at an audit meeting, resident doctors reported being made to feel at fault despite the rota coordinator having provided 6 weeks’ notice to the operations team that the list was uncovered.

Trainers acknowledged these difficulties and noted that the trust sites’ location creates challenges for resident doctors who do not live locally. They reported that some complex cases can finish at 11PM, creating additional challenges for those traveling between sites or those who do not live locally. The unpredictable nature of such complex cases means it can be difficult to schedule appropriate cover for lists which run outside normal working hours.

Whilst some on call accommodation is available on site and at County Hospital in Stafford, resident doctors raised concerns that the accommodation is not single sex and has shared bathroom facilities. Resident doctors reported that this has led to some of them choosing instead to stay in local hotels with difficulties in reclaiming associated expenses in line with the national framework on travel expenses for resident doctors.

The education team reported that they have raised this issue with senior leadership, specifically referencing the travel expenses policy, which provides for temporary accommodation support where daily travel distances are excessive. They reported ongoing discussions about implementing this policy to better support resident doctors required to work across sites.

Areas that are working well

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Kalpesh Thankey, Quality Deputy Manager.

Review lead: Andy Garnham, Head of School, Postgraduate School of Surgery

Date signed:  26/02/2025

NHS England authorised signature: Prof. Andy Whallett, Postgraduate Dean

Date signed: 03/04/2025

Final report submitted to organisation: 16/04/2025