Executive summary

The acute care pathway is being monitored by the deanery as an ISF level 2 (significant concerns) and as part of this monitoring a learner educator/review was arranged. The deanery also met with surgery and obstetrics and gynaecology resident doctors and their supervisors due to their 2024 General Medical Council (GMC) national training survey results.

Verbal feedback was provided to the Executive Medical Director, Director of Postgraduate Medical Education, Medical Education Manager and Postgraduate Education Coordinator on the day of the visit.

There was 1 immediate mandatory requirement identified to review how the systems in place are communicated and used to ensure that there are no significant delays to patient care once a patient is referred on into the receiving speciality. 

Positive findings from the review include:

• supportive and welcoming culture
• supportive postgraduate team
• good local induction and good quality teaching in emergency medicine

There are 6 mandatory requirements identified these include:

• improving handover structure in emergency medicine
• review the medicine on-call induction and local inductions
• ensure service provision in medicine does not impact on training experience and teaching opportunities
• ensure consultant oversight of rotas in medicine and improve communication between the rota team and consultants
• review how the handover list is used in general surgery
• ensure there is clinical oversight of the rota and workplans in obstetrics and gynaecology (O&G) to ensure resident doctors meet their curriculum requirements

An action plan for the immediate safety requirement was requested from the trust by 11 March 2025. A senior leadership meeting to discuss the report will take place with the trust on 4 June 2025. 

Review overview

Background to the review

The deanery last met with resident doctors in medicine and emergency medicine in November 2021. At this time the acute care pathway was under GMC enhanced monitoring and monitored as an ISF level 3 (major concerns) These specialties had been under GMC enhanced monitoring since July 2015.

Following sustained improvement GMC enhanced monitoring measures were removed in February 2023. Following removal of the measures it was agreed that the concerns around the acute care pathway would be monitored as an ISF level 2 (significant concerns). The GMC asked that supportive environment and handover continue to be closely monitored.

The deanery held a senior leadership team meeting with the trust on 12 January 2024. Due to the sustained progress with improving handover, the deanery closed this part of the concern. The acute care pathway including supportive environment continued to be monitored as an ISF level 2 concern (significant concerns).

The deanery last met with resident doctors in obstetrics and gynaecology (O&G) in December 2021 due to deteriorating GMC national training survey (NTS) results; this was a positive visit. There are 7 red outliers in the 2024 GMC NTS survey including for overall satisfaction.

Due to double red outliers in general surgery foundation year 2 for overall satisfaction, clinical supervision and induction and a red outlier for rota design the deanery also met with this group of doctors.

Who we met with

Learners:

• 4 foundation doctors in emergency medicine
• 5 foundation doctors in medicine
• 7 internal medicine training (IMT) doctors
• 2 GP specialty training (GPST) doctors
• 4 specialty training resident doctors in GIM/AIM
• 4 specialty training resident doctors in O&G
• 2 GPST in O&G
• 4 foundation doctors in general surgery

Educators:

• 5 emergency medicine consultants
• 7 GIM/AIM consultants
• 4 O&G consultants
• 2 surgical consultants

Education team:

• Executive Medical Director
• Director of Postgraduate Medical Education
• Medical Education Manager
• Postgraduate Education Coordinator

Review Panel 

• Mr David Ross, Associate Postgraduate Dean and Quality Review Lead
• Professor Simon Carley, Associate Postgraduate Dean
• Professor Paul Baker, Deputy Postgraduate Dean, North West School of Foundation Training and Physician Associates
• Dr Raghu Paranthaman, Deputy Postgraduate Dean
• Dr Ruth Gottstein, Associate Postgraduate Dean
• Dr Richard Parris, Head of School, Emergency Medicine
• Dr Sarah Langston, Training Programme Director (Mersey), Emergency Medicine
• Dr Ray Keelan, Associate Head of School, Medical Specialties
• Dr Nira Ramachandran, Training Programme Director, O&G
• Jan Codling, Lay Representative
• Paula Fletcher, Quality Support Manger
• Lyndsey Dodd, Education QA Manager, GMC
• Carole Aitken, Quality Coordinator
• Leanne Moore, Quality Coordinator
• Shelley Cunliffe, Quality Coordinator

We would like to thank the medical education team for facilitating the sessions with resident doctors and their supervisors and for making the visiting team from the deanery feel very welcome.    

Review findings 

Foundation doctors emergency medicine  

Domain 1: learning environment and culture

Handover

Foundation doctors confirmed there are 3 handovers that take place at 8am, 3pm and 10.30pm and tasks are allocated at handover. The panel heard that the consultant in charge will lead the handover and provide a safety brief at each 1. Datix safety issues are also discussed. They said handover can be educational but is variable.

1 foundation doctor said handovers can sometimes be disorganised compared to medical handovers they had experienced as a foundation year 1 (FY1) doctor. They said handovers are conducted in a random order, they felt haphazard and needed more structure. They felt this would make them safer and more efficient. Other foundation doctors in the group commented that the quality of the handover depended on who was leading it.

Foundation doctors were asked what they felt would improve handovers and replied that a structured handover template would help.

Clinical supervision  

The panel heard that the ‘consultant rota’ is staffed by both consultants and associate specialists or staff grades. Resident doctors stated that clinical supervision they receive can be variable.

Domain 2: educational governance and commitment to quality

Equality, diversity and inclusion  

Foundation doctors said the team is very welcoming and being a diverse team helps. They reported that patients treat them with respect. They felt if they saw someone being treated unfairly, they would escalate either to their educational supervisor, foundation coordinator or Freedom to Speak up Guardian.  

Domain 3: developing and supporting learners

Induction

Resident doctors described their local induction as thorough. It included a tour of the department, lectures as well as practical elements; for example, seeing trauma cases. 1 foundation doctor described the induction as “the best induction so far”. Following the trust induction some foundation doctors felt they had a sense of the culture of the trust.

Rota management

The panel heard that 6 weeks notice is required when submitting annual leave requests with little flexibility in the rota. 1 foundation doctor had requested leave before their rotation which was less than 6 weeks’ notice and although not granted the rota team did try to accommodate their request. Foundation doctors explained that the rota team consists of 2 rota managers who are non-medical, however they said there is some consultant input.

Foundation doctors were asked if the rota aligned them to different areas within the emergency department and if the rota was equitable. The panel were told that resident doctors are not aligned to a particular area, and they go where they are needed, and are verbally allocated to an area on the day. However, if they ask to go to a certain area to gain exposure this will be accommodated.

Out of hours

Foundation doctors felt they receive more opportunities and feedback out of hours. They commented that senior resident doctors are very keen to teach. An example provided included a resident doctor being able to be involved with fractures and manipulations with a consultant prior to the patient going to orthopaedics.

Workplace based assessments (WBAs)

Foundation doctors had no difficulty in getting their WBAs signed off and commented that this is the best job to get cases signed off. They confirmed they are not a tick box exercise and are a 2-way interaction.

Educational supervision

All foundation doctors had a named educational supervisor who is supportive and understands the foundation portfolio.

Formal teaching

This takes place each Thursday for an hour and was described as “very good”. This hour is protected and described by 1 doctor as the “best they have had”. The teaching is delivered by a consultant and senior resident doctor and is case based. They said they are always released for teaching unless they are on-call or there is a busy rota but said the department are good at releasing them to attend.

Domain 5: delivering curricula and assessments 

Training experience

Foundation doctors explained they can get the exposure they require to meet their curriculum needs. The panel heard that seniors are very open and listen to what foundation doctors would like to do and accommodate their requests. Foundation doctors will discuss every patient they see with a senior therefore they receive ample opportunity for feedback and to get their curriculum requirements signed off.

A foundation doctor with an interest in burns informed a senior of their interest and was given an opportunity to be involved in a burns case with the registrar. The panel also heard that the training registrars are good at getting foundation doctors involved in high acuity cases. They said they do not feel pressured to see patients within a certain time frame and commented that senior resident doctors are very supportive.

Foundation doctors explained the structure of the other doctors that work within their tier and felt that supervision levels are good, and they are appropriately supported. They explained that there is a consultant at the main desk in majors who is available to discuss patients with and overnight there is a registrar available. They explained that ST3+ resident doctors act autonomously and said there is a box on the Electronic Patient Record (EPR) form to tick what level of clinician you are. They said this box is not mandatory, but it is expected that it is completed.

Foundation doctors were asked if there is enough time for supervisors to consider their thinking? They explained they are expected to have a plan for the patient prior to speaking a senior resident doctor/consultant. They said the feedback is always positive with suggestions to consider.

Foundation doctors confirmed they do not undertake a disproportionate amount of tasks with limited educational value. They commented that the physician associates (PAs) in the department are great to work with and are happy to teach them skills. They said there are currently around 4/5 PAs in post with some having left recently. They confirmed that PAs are well embedded in the team.

Recommendation of placement

Foundation doctors in emergency medicine were asked if they would recommend their placement at Warrington Hospital and all said “yes”

When asked what the good things are about their placement, responses included:

• enjoying the undifferentiated presentation
• supportive environment
• opportunities to work on resus has improved confidence
• steep learning curve and job satisfaction

When asked what they would like to see improve, responses included:

• handover
• how they are allocated on the rota to ensure that their work environment aligns with their training needs

Emergency medicine supervisors

Domain 4: developing and supporting supervisors

The panel lead fed back that their foundation doctors are having a positive experience in the department.

Programmed activities (PAs)

Supervisors confirmed they had PA time in their job plan, and they hold regular faculty meetings to discuss resident doctor progress. The panel heard that as of September 2024 locally employed doctors (LEDs) now have educational supervisors. This is something that consultants have been working towards for a while and felt strongly that support was needed for doctors new to the country and the NHS.  

The panel heard that there is no specific LED/international medical graduate (IMG) programme but is something they are working towards. They are also working towards LEDs being able to exception report. As a department they feel they are very supportive of LEDs/IMGs to aid their development and ultimately encourage them to stay within the department on a longer-term basis.

The clinical educator role was previously split between 4 consultants; however, this is no longer included in job plans and no longer funded by the trust. This post was funded by the trust for a further year following the initial pilot which had 50% funding from Health Education England. The supervisors felt this role added value and there are people in the department who would like the role if funding was available.

Supervisors confirmed that education forms part of their appraisal, they confirmed it is not mandated to be a trainer as part of their consultant role, but it is expected. They said they attend external courses and said consultants and registrars teach on Thursdays.  When asked about postgraduate educator days some consultants were unaware if the trust did any. They were asked if in house educator continuing professional development days would be well received and consultants unanimously replied “yes”.

Equality, diversity and inclusion

The panel heard from a consultant who is the co-chair of the LGBTQI network.  They explained that regular staff surveys are undertaken, and the network reacts to the data they receive. Supervisors explained that the medical workforce at the trust is not representative of the local population and has a nice culture. 1 consultant said they have been at the trust for 15 years and could “count on 1 hand” the number of diversity issues witnessed. They are supporting some resident doctors who are neurodiverse and would like training around supporting resident doctors with neurodiversity.  (There are resources available from the Lead Employer).

The consultants described a cultural issue within the department involving a resident doctor and a supervisor from different cultures. This was dealt with immediately and escalated to the Director of Postgraduate Medical Education (DME), Training Programme Director (TPD) of the resident doctor and the Clinical Director. The panel heard this was managed to the satisfaction of the resident doctor involved.

The panel were informed that the Clinical Director also spoke with the supervisor involved, however, this has happened again. Supervisors were asked how can they be proactive to ensure this does not reoccur, and do they have the ability to call out this behaviour? Supervisors explained they had an acting Clinical Director last year and there was no clear structure, therefore who could they escalate to. They explained that a new Clinical Director was appointed before Christmas and a new Clinical Lead is currently being appointed.

Supervision

Consultants explained there are 16 people on the consultant tier, consisting of 14 consultants and 2 associate specialists that provide on-call. They said they have a meeting each Wednesday to discuss, performance, audit, and mortality. They also have a WhatsApp group and an education meeting every other month to discuss resident doctors’ progress. The panel heard there are potentially an additional 4 consultants being recruited.

1 supervisor stated that the consultants are a good team, they meet socially and share a sense of purpose. They said there was a “vacuum” within their governance structure, but the recently appointed substantive Clinical Director has bought the team together and is making things happen.

Feedback

The panel lead fed back from the resident doctor session that they recognised that all care discussions are educational, and the panel lead said it is reassuring that resident doctors understand this.

Supervisors said all specialist and associate specialist (SAS) have an educational supervisor (ES). SAS doctors are also being put through the “Train the Trainer” course. They also explained they were a pilot site for PAs 9 years ago and said that PAs are always supervised and are trusted members of the team.

Working with other teams

Supervisors were asked how they function with other teams. They informed the panel of the Internal professional standards document. They said they regularly meet with the Deputy Medical Director and a group has been set up to discuss any issues they have in relation to professional standards and interactions with clinical teams. The panel fed back that resident doctors they met earlier said they feel supported by their seniors if there is any friction with other departments (when patients are being referred on from emergency medicine).

Supervisors were asked if they are listened to by the executive team? They said they can raise problems at governance committees, they have a departmental risk register and have monthly governance meetings.

When asked if there was anything they would like to raise with the deanery, some consultants replied that rota gaps and less than full time doctors (LTFT) has an impact on resident doctors as there can be a struggle to cover night shifts. They said that sometimes consultants step down to ensure there is supervision at all rota levels.

Supervisors were asked if they had considered self-rostering, as it can help improve the rota, help to reduce costs and is also an integral part of resident doctor well-being. They replied that they had considered this, as they currently use Medi-Rota. The Head of School advised that Oldham Hospital are a leading light in this area if they were considering self-rostering.

Foundation doctors medical specialties

Domain 1: learning environment and culture

Handover

The panel heard that handover is working well apart from Ward A8 which has 2 long handovers each day leaving little time for jobs.

Raising concerns

All of the group were aware of the Datix system however 3 of them did not know how to use it. None of the group were aware of any feedback from Datix reports.  All of the group knew how to escalate any concerns they may have.

Exception reporting

All of the group were aware how to exception report and have done so when required.

Working relationships

The group felt that the trust was a friendly place to work. They said the foundation team is very helpful. Some foundation doctors identified Ward A8 as being less supportive. When asked if the medical education team are supportive, they replied “yes, absolutely”

Domain 2: education governance and commitment to quality

Equality, diversion and inclusion (EDI)

None of the group had any negative experiences in relation to EDI involving staff or patients.

Quality of care

Foundation doctors were asked if they would send a loved one for care at the hospital. Most of the group would not recommend the trust for care due to workload, lack of time and the pace. 1 foundation doctor commented that quality of medical decision making is amazing.

Domain 3: developing and supporting learners

Induction

The panel heard that the August induction was good, however later inductions consisted of a slide set that did not work well. Some foundation doctors said they were informed via email that they would receive a departmental induction in December; however, this did not happen. They said they did not feel well prepared for on-call as the induction received, they felt was poor. This also consisted of a slide set with little narrative or explanation. The panel heard that protocols are available but are not explained. They explained they are long documents and are not adapted for use in an on-call situation.

Workload

The panel heard that resident doctors experience is variable; some wards are good, and workload is manageable. However, sometimes the workload can feel overwhelming. 1 doctor said they still feel overwhelmed even when they are able to delegate some of their tasks. They commented that some senior resident doctors do not have always have the time to support them based upon the number of doctors and patients at Warrington.

Domain 5: delivering curricula and assessments

Training experience  

The panel heard there are limited teaching opportunities and all foundation doctors in the group said there is no bedside teaching at all. 1 foundation doctor said, “I feel like I am just coping”. 1 commented they never really receive feedback and felt the role was largely service provision.

1 doctor commented they have learnt whilst on-call as there was a senior resident doctor to guide them, but said in medicine you have to try to “stay afloat”. The panel heard their experience on ITU was good.

The panel heard that sometimes foundation doctors are asked to act outside of their competencies. For example, undertaking independent ward rounds and an example of a FY1 doctor being asked to take consent for a chest drain insertion was heard. A consultant subsequently explained to them they were not supposed to do this.

Some of the group said they are getting better at saying “no” if asked to act outside of their competencies.  

The panel heard that they do not always have an opportunity to attend outpatient clinics. They felt that a lot of ward responsibility is forced onto FY1 doctors and sometimes they are unable to bleep a senior resident doctor but there is a team they can contact in this instance.

The panel heard that FY1s often have to stand in for phlebotomists on some wards. Ward A8 was mentioned. A foundation doctor stated there is a difference between medicine and surgery and has been asked to undertake phlebotomy whilst in medicine without nurses or other health care professionals being asked. It is expected on some medical wards that foundation doctors take bloods.

Other foundation doctors had varying experiences regarding being asked to take bloods and this varied between wards.

Teaching

The group said they receive 3 hours per week teaching which they felt was good. This is followed by 1 hour of self-development time and there are also opportunities available for peer teaching. The panel heard there can sometimes be difficulty getting released to attend teaching due to workload and said it was difficult to catch up on missed teaching due to ward workload.

The panel heard that the group felt that self-development time works better when bundled into days or half days.

Recommendation of placement

Foundation doctors in medicine were asked if they would recommend their placement at Warrington Hospital and 3 said “yes” and 2 were unsure. When asked what the good things are about their placement, responses included

• staff and culture
• good location

When asked what they would like to see improve, responses included:

• more staffing
• fill LTFT gaps in advance as the trust knows where they are
• doctors ‘mess’ – there is one but is not very good. Funding to make this a more relaxing space.

Internal medicine training (IMT) doctors and GP speciality training (GPST)

Domain 1: learning environment and culture

Handover

The panel heard that handovers work well on both the wards and the acute take.

Supervision and feedback

When asked if they have access to senior support the panel heard that during the day there are usually 1 or 2 consultants between 1-5 pm. Compared to other hospitals resident doctors felt acute cover is good but difficult due to the high number of patients.

They felt that receiving feedback depended on the consultant, and said some consultants will tell them when they are doing something they can use for an acute care assessment tool (ACAT).  The panel heard that acute medicine is good for providing feedback.

The panel heard that on a general medicine ward there are only 2 consultant ward rounds per week, which they felt was unsafe. Resident doctors have to refer to a specialist at all times and said it would be better if they had a registrar on the ward. They explained that specialties do not come to the ward they are “our” patients. They said the ward feels like an outlier ward with patients waiting to be seen by the specialty department.

All resident doctors were very complimentary about the PACES training provided by a respiratory consultant.

Domain 2: educational governance and commitment to quality

Equality, diversity and inclusion (EDI) 

The group said the culture at the trust is very good and is better than some other trusts they have worked in. None of the resident doctors said they had any issues in relation to EDI concerning staff or patients.

Domain 3: developing and supporting learners

Induction

IMT and GPST doctors described a mixed experience of induction. Some resident doctors did not receive a departmental induction whilst some had an induction but were not shown around the hospital. 1 doctor said the induction lacked information for on-call duties. The panel heard that respiratory has a pre-recorded video from a consultant as part of their induction.  Some resident doctors had difficulty with Lorenzo the trust’s Electronic Patient Record (EPR) on line training and there was no one available to help.

A resident doctor said when they commenced on the stroke ward a PA came to explain what they do, then other staff came over and a consultant introduced themselves. Everyone was friendly, but there was no structure to the induction.  

Resident doctors acknowledged that is difficult to provide inductions that cover everything but commented that the medicine induction was not particularly good.

Workload

Resident doctors described a busy acute take with 25/30 patients waiting to be seen. They said the list never clears and stated there is a 19 hour wait today. There were some concerns about prioritisation of referrals but said that A&E have a priority list for seeing patients. They said some resident doctors cover wards, A&E and Medicine Emergency team (MET) calls. They felt happy with the quality of work on the take and said most consultants are approachable.

MET calls (NEWS 7+) are covered by middle grade doctors. The On-call team will allocate roles.

The panel heard that A&E do not need to discuss with the department for referral and there has been occasions when a patient is in the wrong place and found 24 hours later and/or have waited a significant period of time before being moved on. They also explained if there is a busy night on the wards then A&E and Same Day Emergency Care (SDEC) Unit patients will be left where they are and not referred onwards.

Some resident doctors felt they do not get enough time on the wards. The panel heard an example from an IMT doctor who between January and April did not have any shifts on their base ward as they were on-call, had rest days or annual leave. They said ward staff had thought they had rotated as they had been away so long.  

The panel heard their experience is made up of 60% on-call duties and 40% specialty experience. IMT 3 doctors said they have an on-call every week and it is almost impossible to take any annual leave.

Domain 5: delivering curricula and assessments

Training experience

Clinics are available and there is a clinic week on the rota, but it is up to the resident doctor to select the clinics and get approval which they felt they can sometimes waste time trying to secure lost opportunities. The panel also heard that sometimes resident doctors are taken out of clinic to cover the SDEC Unit. However, when they do get to clinic, they said it is a great experience.  

Recommendation of placement

IMT and GPST doctors were asked if they would recommend their placement at Warrington Hospital, 5 said “yes” and 4 said “no” The resident doctors that would not recommend the trust said this was due to the workload. All 9 resident doctors said they would warn others of the workload at Warrington before starting a placement.  

Specialty resident doctors in medical specialties

Domain 1: learning environment and culture

Handover

Resident doctors felt that on-call and ward handovers were robust and structured, they are often attended by a consultant and registrar led.

Domain 2: education governance and commitment to quality

Equality, diversion and inclusion (EDI)

Resident doctors from both diabetes and endocrinology (D&E) and geriatric medicine said the department culture is very good and are well supported, by their supervisors and the wider team.

Domain 3: developing and supporting learners

Induction

The panel heard that trust induction is good, however resident doctors described a varied experience of local induction. Specialty induction was absent or low quality in many cases. A resident doctor felt the IT online session was not sufficient as they did not feel ready to use the EPR and were still asking questions a week later for example how to complete discharge summaries. This issue was also raised by the IMT and GPST resident doctors in the previous session. Resident doctors also said they received a PowerPoint presentation about on-call including handover times and what each bleep means. A resident doctor in cardiology did not receive an induction and took the initiative to go to the ward and introduce themselves. The ward was not expecting them.

In D&E resident doctors are sent a video and resident doctors in the speciality had met their clinical supervisor.

Rota management

A resident doctor in cardiology described the rota team as proactive and were excellent in helping them arrange paternity leave. A cardiology resident doctor shared their concerns regarding the amount of training they will receive as their timetable does not have any face-to-face clinic time or CT/MRI in it and told the panel they had a meeting about these concerns later that day.

The panel heard that a cardiology doctor had been put on the clinical fellows rota (there are 7 clinical fellows) which they are unhappy with.

Resident doctors confirmed they have supporting professional activities (SPA) time on their rota.

On-call rota

All of the group agreed that the on-call rota is 1 of the heaviest they have experienced and said it was compounded by rota gaps at all levels. 1 resident doctor said they had started on nights over a weekend, and they were the most senior doctor on the shift with 4 foundation year 1 (FY1) doctors. Whilst on-call the panel heard that resident doctors are pulled between MET calls, and supporting FY1’s. However, they can always contact a consultant.

The group explained the frequency of the take to the panel. They said they have 1 long day a week and weekends are 1 in 4. When they do a weekend of nights they are then not in until the next Monday. 1 doctor commented that it is difficult to take annual leave as there is only 1 week when they do not have on-call responsibilities.

The panel heard from higher specialty resident doctors there are sometimes significant delays in the time from a patient being referred to being seen by a senior decision maker in the receiving specialty.

Resident doctors told the panel that the level of safety for the acute take can depend on the quality of management plans received from emergency medicine. The panel heard that this has led to incidences of critical medication not being prescribed. Resident doctors described some emergency medicine physicians as “anxious” and regularly flag everything as “urgent” They felt that sometimes the prioritisation of patients is not visible and can lead to the highest acuity patients not being prioritised.

An example was provided whereby a patient was seen by emergency medicine at 6.30am and given 1 dose of antibiotics. The patient was not prescribed anti-epileptic medication and were seen by a medical speciality resident doctor at 7pm that evening and were floridly septic. The patient did not have a fit. This was reported via Datix.

The panel heard from resident doctors that there are systems in place including a critical medication policy and a purple box to flag that the patient should be referred directly to medicine. However, this box is not always used by Accident and Emergency (A&E) coordinators.

This was fed back on the day of the visit to the Executive Medical Director and Director of Postgraduate Education as an immediate mandatory requirement and an action plan was requested by 11 March 2025.

Domain 5: delivering curricula and assessments

Specialty experience

The panel heard there was a lack of substantive consultants in geriatric medicine, but this is improving. Resident doctors said there are currently 2 substantive geriatric consultants and 5 locums, and they felt supported.

Resident doctors were asked if they felt they would meet the competencies required by their curriculum. They replied that in D&E there are clinics timetabled each week, but they have difficulty getting to them due to on-call duties. Resident doctors in geriatric medicine also said they have difficulties with clinics. For example, opportunities to undertake osteoporosis clinics and they explained there is a “battle” for rooms to deliver clinics.

Recommendation of placement

Specialty resident doctors in medicine were asked if they would recommend their placement at Warrington Hospital, 3 said “yes” and 1 said it was too early in their placement to say.

Medicine supervisors

Domain 4: developing and supporting supervisors

Rota

A consultant in the group introduced themselves as previously working at Warrington as an IMT doctor who resigned in 2013 due to their training experience and came back as a consultant in 2019 as it is much improved. Consultants stated it can be a challenge to provide education with the volume of patients to be seen. They also said there are rota gaps on most shifts and LTFT doctors has an impact on the rota. This can impact upon patient numbers as they build and are then handed over the next day. They said there are known gaps up to 2 months in advance with no planned cover and said that no single consultant has the time or authority to influence the rota. No named consultant is responsible for the rota. Consultants were asked where the block is for them getting involved in overseeing the rota, what are the issues preventing them from influencing the rota? Consultants said they have tried to influence the rota, but no one has the authority or time to deal with it.

The panel heard there is a clear communication gap between the rota team and resident doctors. They explained that the rota team consists of 3 people, there is a Medical Utilisation Manager (MUM) with 2 people supporting them with the rota. Rota gaps are known, and the MUM is limited in escalation rates and are often left with rota gaps. Supervisors said they try to attend rota oversight meetings.

Consultant rota

Rota gaps at consultant level have improved, supervisors explained there are 6 consultants in the morning covering acute medicine and the take, there are 3 in the afternoon and 2 in the evening. There are 9 substantive consultants in acute medicine. In respiratory medicine there were 3 consultants and there are now 6 substantive consultants and 1 long-term locum. In D&E there were 5 consultants and there are now 6. They said there is good acute medical presence in A&E.

The panel fed back from the previous session regarding long waiting times for patients in A&E, for example, 19 hours wait today. Consultants said this varies as at the weekend it was 2 hours. They said that 50% of patents in A&E are medical patients and the Clinical Director is reviewing the acute medical input into A&E. Consultants said the department are currently experiencing the backlash of recruitment decisions previously made to resolve staffing problems in the emergency department. They explained the issue is the workforce mix on the emergency department rota, which is largely staffed by PAs and IMGs. As PA’s cannot prescribe, if there are 6 PAs on shift then consultants are reviewing their prescriptions. Additionally, IMGs can struggle as some do not have any experience of working in the UK and may not be operating at the same level as an NHS trained doctor. This can then impact on the training experience of resident doctors.

Induction

The panel fed back to consultants that some resident doctors said their specialty and acute induction was variable. Consultants explained that the on-call induction is mainly provided by the rota team. They said there is a 20-minute slot for a consultant to attend. When asked if they felt the induction works well some thought it worked well with others stating that ideally it would be a consultant that undertakes the induction but due to clinical pressures this is not possible.

Consultants clarified that all specialty inductions include a 10-minute introduction for resident doctors, and they take place consistently every 4 months. Respiratory medicine has a local induction pack for all grades. The panel heard that a booklet is also provided for acute medicine including a welcome letter, secretaries numbers etc.  It was fed back that this did not match with resident doctors’ experience of induction. It was not apparent from the resident doctors the panel had met with that consistency of induction was applied throughout the year. For example, those resident doctors who started out of sync.

The panel also fed back that resident doctors said their WBAs are good and there is a friendly culture in the departments. Consultants confirmed there is a medical hub in the emergency department which has a room for consultants that helps resident doctors with their assessments.

Teaching

The panel informed the supervisors they had heard variable experiences from resident doctors regarding formalised teaching including cardiology. Consultants explained that about 1 and a half years ago respiratory and cardiology teaching was merged so 1 week it was respiratory and 1 week it would be cardiology and said they are now struggling to get cardiology teaching sessions.

Support

Supervisors were asked if, as heard from resident doctor sessions, sometimes patients can sit on a ward a long time before they are reviewed by a senior decision maker. Supervisors explained that consultants do a ward round each day and any problems resident doctors have they can discuss with them and there is a consultant of the week. They stated that is trust policy to see every patient every day.

Supervisors were asked what mechanisms exist to understand if resident doctors are meeting the necessary standards at the end of a rotation. The panel heard that they are close consultant body and discuss the resident doctors and will have an early conversation if there is an issue. Portfolio progress is tracked so they know if a resident doctor is falling behind.

When asked if there were any specific areas, they would like support to resolve consultants were keen to highlight the rota management issues that were discussed earlier in the session, they felt that consultants are not being listened to despite their efforts which impacts on resident doctors’ experience.  

They expressed frustration that sometimes the acute medical registrar is off the AMU to support the on- call, as the rota gaps are known.  

Foundation doctors general surgery

Domain 1: learning environment and culture

Handover

Foundation doctors explained that there is a morning consultant led handover, and a registrar led afternoon handover.   

The panel asked foundation doctors how would they handover a patient who is acutely unwell as they were leaving their shift.  They explained there is a list they can add a patient to, and this will ensure they are discussed at handover. However, the panel heard an example from urology where a patient was missed from the list as there was an assumption they were under the medics, they were not reviewed for 2-3 days and subsequently developed a DVT. Foundation doctors were unsure if this could have been prevented if the medics had seen the patient.

Domain 2: educational governance and commitment to quality

The panel heard that a foundation doctor had experienced negative comments from a senior doctor regarding a recent political situation. They raised this with the Foundation Programme Director and said she dealt with this very professionally.

Another foundation doctor had been physically assaulted by a patient, allegedly due to their race and did not feel it had been dealt with very well. Police refused to arrest the patient as the resident doctor had gone home. The patient was later arrested as they verbally assaulted another member of staff. There was a delay with the police getting back to the doctor and the consultant who had to complete the paperwork had since retired, so the police dropped the charges. However, the foundation doctor said there was another consultant that had witnessed the incident that could have completed the paperwork.

Domain 3: developing and supporting learners

All said they had received a good induction. Foundation doctors were asked if their induction covered pathways, for example, which referrals to accept from A&E. They said they were unaware of any pathways and learnt on the job and from speaking to registrars.

When asked about the rota they said sometimes leave is rejected due to short staffing.

All of the group said consultants encourage them to go to theatre, but the reality is due to their workload they do not get the opportunity to leave the wards. Foundation doctors in breast surgery and colorectal surgery said they have had allocated theatre time.

The panel heard that sometimes things may get missed but there have been no incidences of patient harm as a result. Examples heard included patients’ regular medication may take an extra day to be prescribed or bloods that are to be reviewed the next day are missed. This is due to the workload.

Foundation doctors felt supported and can always contact a registrar, they stated that 90% of the time it is FY1 or FY2 on the ward. FY1 doctors do not see patients on their own. A FY2 doctor said they have done a ward round with a FY1 as there was no consultant. However, the patients on the ward were stable, had been on the ward 3/4 days and had previously been seen by the consultant.

In trauma and orthopaedics (T&O) all newly admitted patients will be seen by a registrar and seen by a consultant by the next handover. The panel heard that foundation doctors in T&O are ward based, and the registrars are hands on as there are a lack of middle grade doctors in the specialty. For example, they undertake first management steps such as wrist fracture manipulation. The panel heard that sometimes there are delays in patients being seen by a senior, an example provided was as a FY1 doctor there have been times when it has taken 2 days for a consultant to review the patient.  

In some circumstances orthopaedic patients are not seen by anyone more senior than an FY1 doctor for days. Some of the foundation doctors felt that some consultants try to persuade FY1s into taking on a heavier workload than they feel comfortable with.  

None of the foundation doctors had seen any patient safety concerns as a result.

In T&O the foundation doctor reiterated that they did not make any discharge decisions, the patients were ward based and post operative. If there are any issues, they can escalate to the registrar at Warrington or the registrar at the elective site at Halton. They explained there is also an orthogeriatric consultant and trust grade ortho geriatric doctor.

Domain 5: delivering curricula and assessments

Foundation doctors were asked if they are asked to act beyond their competencies and 1 replied they were bleeped jobs that were not at their level last week and felt able to reject them.

Foundation doctors were asked if their placement met their development needs. 1 foundation doctor felt that FY1 left them under prepared for their role as an FY2. Some of the group felt that through working in urology and ENT they had learnt a lot.

Foundation doctors confirmed that in general surgery and T&O their roles are ward based and said there is little flexibility in the work plans to observe in theatre as they are busy on the wards. They said it would be helpful if consultants could help facilitate time to observe in theatre. They said the ANPs, and PAs are “great”.

Foundation doctors said they can learn from their work and FY1s said they feel they are a better doctor and have learnt a lot from the registrars.

They were asked if they receive the 2 hours self-development time they are supposed to receive. They said they do but 1 hour can be before teaching which they felt is a waste of time.

All said they had a named educational supervisor who are aware of their curriculum needs.

Recommendation of placement

All surgical foundation doctors said they would recommend their placement at Warrington. They said the best parts are the people they work with. When asked what they would like to improve they said:

• the volume of work as they always feel they are a member of staff short
• surgical rotation as they should be doing surgery

Surgical supervisors

Domain 5: developing and supporting supervisors

The panel fed back that foundation doctors are happy, but busy. Consultants explained that in urology over bank holidays there are not always FY1 or FY2 doctors to provide cover therefore they act down.

When asked about rota management they explained they have 2 people who manage the rotas. Consultants said they have good relationships with them and said they try to mould the rota to the needs of the foundation doctors. A colorectal consultant said they input into the rota and speak to the rota managers 2-3 times a week.

It was fed back to supervisors that foundation doctors found the workload heavy. Consultants explained that 10 years ago there was 1 registrar an SHO and FY1 covering on-call and there are now 5 FY1s at the weekend. At registrar level the ratio is 1 in 8 so it is harder when there are rota gaps.

Supervisors confirmed that as educators they have time allocated in their job plans. There is no time in their job plans for supervising PAs.

Consultants said the 2 staff members responsible for the rota will highlight any problems to them that any foundation doctors may have.

Consultants were not aware of any issues in relation to equality, diversity and inclusion and said there are reporting systems in place.

Supervisors were asked how they collated feedback on how the foundation doctors are progressing and how, as a group, do they form a view of a resident doctor? They said they receive informal feedback from the 2 members of staff that manage the rotas as they are very good at liaising with foundation doctors. Consultants also meet as a group to discuss resident doctor progress. They felt this was ad-hoc and does not work as well as it could. They said they do not have many resident doctors that require extra support.

Obstetrics and gynaecology (O&G) resident doctors

Domain 1: learning environment and culture

Rota

Resident doctors explained that the rota for ST2 and below is 1 in 8 and for those ST3-5 is 1 in 7 which is very heavy. They said the rota has around 60% of doctors who are LTFT which makes the rota complex. They said there is not always clinical oversight of the rota and as the Rota team may not understand their curriculum requirements resident doctors are put on the rota to fill gaps.

The panel heard that rotas are not always sent in advance. Resident doctors explained that there is little flexibility in the rota, there is no consultant oversight, and the rota is overseen at specialty training level.

Resident doctors also said that at core level clinics are not included on the rota.

The panel heard theatre time is included on the rota, however with no consultant oversight they may never get to clinics. On study days they shadow nurses in the community. They receive 2 training sessions per month.  

Handover

The panel heard there are multiple handovers taking place at 8am, 1pm, 5pm and 8pm. The evening handover is registrar led with a consultant present. At the morning handover a registrar hands over to a consultant. The other handovers are registrar to registrar. Resident doctors confirmed there is a system to ensure that patients are not lost.

Domain 3: developing and supporting learners

Induction

Resident doctors described a variable experience of local induction. The panel heard that some had an individualised induction whilst others felt their induction was just standard. The Gynaecology Assessment Unit (GAU) has a specific book that helps and has an excellent Advanced Practitioner who really helps resident doctors who are new to the unit.

Some resident doctors felt there could have been more support with using the IT systems as they can be difficult to use. The panel heard there were 3 different systems they have to use. A resident doctor shadowed a specialty resident doctor to understand the system more. Resident doctors suggested that the following would improve induction

• more support to use IT systems
• shadowing
• a walk round of the different environments

Support

Resident doctors said the consultants are all supportive and approachable and are ready to come in out of hours if needed. Mr Paul Adinkra was described as “very supportive” and the whole team were described as “brilliant”.

Training experience

A speciality resident doctor said they get what they need to meet their curriculum requirements from the placement and GPST doctors confirmed they have study days.

Resident doctors said their scan training needs organisation as some resident doctors have to come in on their days off to attend. They explained that scanning takes a lot of organising on their part and takes a lot of effort from resident doctors to make sure they get what they need for their curriculum requirements.

An O&G ST resident doctor said there is lots of clinical activity and said that last year locums were getting used to doing the theatre list which resident doctors felt was unfair and said 1 in 8 would really help. They said that the administrative team no longer advertise theatre slots to locums. An O&G ST resident doctor said there are 4 consultants who have different theatre slots and has had to speak to someone to get the amount of theatre time they need and commented “we really need someone who knows what we need doing the rota”.

The panel heard that the workload at weekends is heavy.

Resident doctors were asked if they had sufficient clinical control of their workplan?  All agreed that the main issue is the management of the rota.

Recommendation of placement

All O&G resident doctors said they would recommend their placement at Warrington. They said the best parts are the people they work with and a supportive consultant body.

Areas they would like to see improve included the rota especially over the weekend and the rota administrative team.

Obstetrics and gynaecology supervisors

Domain 4: developing and supporting supervisors

The panel fed back that resident doctors feel well supported and would recommend Warrington as a great place to train. They also fed back that they were complimentary regarding the wider multi professional team.

Job planning and continuing professional development (CPD)

Supervisors confirmed they have job plans and explained they only receive job plan time for specialty training resident doctors.

They said they meet with resident doctors every few months and said it helps when resident doctors are proactive in arranging meetings.  

They explained that they use the SARD system that sends supervisors monthly reports of whose appraisal is due. None of the consultants in the room are appraisers.

The panel discussed expansion with 2 supervisors considering taking the formal appraiser qualification.

Supervisors were asked about educational CPD and how they maintained their skill set. They felt that CPD offered by the trust is not as good as it used to be. They felt that the educational faculty are not proactive with them to ensure they are up to date. They said they can get professional leave easily enough but felt the trust itself is not very good at providing in house training. They said the University of Liverpool provides CPD sessions which they attend.  

Equality diversity and inclusion

As a multi-cultural team supervisors said issues rarely arise.  The panel heard of an example of a member of nursing staff who wanted to pray and received negative comments from another staff member. Consultants called this behaviour out and dealt with the situation.  

Rota management

The panel fed back regarding the rota discussions they had with resident doctors and the challenges they face.

Supervisors acknowledged the lack of consultant oversight of the rota and that they are working to resolve this. They also explained there has been a lot of sickness within the Rota Coordinator team. They explained they have advertised 2 locum appointment for service (LAS) posts and have appointed to 1 post and appointed to the other for a 6-month period.

They said they have tried several ways to provide training sessions but with the rota and LTFT resident doctors the numbers are small. They stated it would be helpful if the Royal College could stipulate how much clinic/theatre time etc is required (as is done by the JCST for surgical specialties).

The panel highlighted that while GPST doctors should be attending gynaecology clinics, consultants explained that they do not have space to accommodate them. An example heard was a consultant having 22 patients in clinic and a brand new ST1 in clinic and said it can be hard to balance service provision and training.

Supervisors said that resident doctors should receive half a day per week self-development time and if they are having difficulty in attending, they should raise it with their educational supervisor.

Support

Consultants were asked how as a group they allocate supervision of resident doctors according to ability and current patient need? The panel heard that, all foundation doctors are allocated 1 supervisor and GPST doctors are shared between supervisors, so they have a variety of resident doctors. Other grades of resident doctor are allocated by what their training needs are, and which consultant can best meet their training needs.

Monthly consultant meetings take place with the exception of August.

Areas that are working well

Areas for improvement

Immediate mandatory requirements

Mandatory requirements

Report approval

Report completed by: Paula Fletcher, Quality Support Manager

Review lead: Mr David Ross, Associate Postgraduate Dean
Date approved by review lead: 13 May 2025

NHS England authorised signature: Dr Raghu Paranthaman, Deputy Postgraduate Dean
Date authorised: 22 May 2025

Final report submitted to organisation: 23 May 2025