Executive summary

The North West Deanery visited Wirral’s Arrowe Park Hospital site on 11 June 2024 to meet with doctors in training in three posts: Obstetrics and Gynaecology, Cardiology, and Emergency Medicine. We also met with the trainers in these disciplines and then finally with the Medical Director and medical education team.

The trust will be glad to learn that there were no patient safety issues to report.

We did find a number of issues impacting on the provision of high-quality education and training in each department, including one key issue with the rota which cut across all programmes. We fed these back in summary to the medical education team and Medical Director at the end of the day of the visit and lay them out in more detail in this report.

All of the doctors we spoke to, from foundation to consultant, shared a view of this critical rota issue, which we characterised as an overcentralisation of rota control with little or no clinical input. When feeding this back to the medical education team, we were pleased to hear that there was a plan to devolve rota design to the divisions.

This ‘overcentralisation’ issue is understood in the context of previous – now resolved – concerns about the trust’s centralisation of educational governance.

We found other themes throughout the day, including barriers to accessing training opportunities, missing inductions, service pressures impacting on education, and on the positive side we heard about highly committed consultants, supportive relationships and a clear and codified set of civility behaviours.

The panel would like to thank the trust for its hospitality and engagement throughout the visit. We will return to the trust for a Senior Leadership Engagement meeting on 25 February 2025.

Review overview

Background to the review

We last visited the trust formally in two linked visits in December 2022 and April 2023, and the key concern at the time was educational governance at the trust. By the end of that programme of work the deanery was assured that there were appropriate escalation routes for concerns, a reduced risk of conflicts of interest including a shared portfolio of accountable leadership amongst the leadership team and adequate governance meetings and structures.

On 28 July 2023 the doctors in obstetrics and gynaecology training at Wirral wrote a letter addressed to both the trust’s Director of Medical Education and the Postgraduate Dean of the North West Deanery, outlining their concerns with the balance of training to service provision, the barriers they were facing in accessing formal teaching and other learning opportunities, and the frustration and burnout that the high workload and lack of educational progression had brought about in many of the doctors in training there.

The National Training Survey 2023 showed significant concerns for doctors in cardiology specialty training, with six negative outliers and eight potential negative outliers out of 17 indicators with data. The same survey collected a group of free text comments which pointed to patient safety concerns related to overcrowding in the emergency department.

Who we met with

Learners

• 8 × doctors in obstetrics and gynaecology posts
• 5 × doctors in cardiology training
• 9 × doctors in emergency medicine

Educators

• Consultants and supervisors in emergency medicine, cardiology and obstetrics and gynaecology

Education team

• medical director
• deputy director of medical education
• medical education and workforce transformation lead
• medical education manager

Review panel

• David Ross, Associate Dean (Education Quality Review Lead)
• Simon Carley, Associate Dean
• Zander Zambas, Education Quality Manager
• Leanne Moore, Education Quality Coordinator
• Shelley Cunliffe, Education Quality Coordinator
• Rowena Jackson, Lay Member

Review findings

Obstetrics and gynaecology

We spoke with a cohort of eight doctors in obstetrics and gynaecology posts, including doctors in general practice training and foundation doctors alongside those in specialist training. We were pleased to hear that most doctors were satisfied overall with the post, and that they talked openly about the positive culture, the close-knit team and the learning opportunities while also being able to articulate the challenges of working in this unit. Most of the criticisms were levelled at the rota and governance around the rota.

We had come with some prior knowledge of concerns which we wanted to investigate, and so were pleased to find doctors who had previously raised concerns with us able to tell us a story of how things have changed over the last year. The were many improvements described for which the trust should be commended. For example, we heard that previously handover had consistently held people back from leaving for up to 45 minutes or so, but that the shift pattern and working day had changed to finish later at 5.30pm to allow for handover and punctual departure. There also appeared to be a collection of staffing shortages last year, including an unusually high number of doctors on maternity leave alongside other absences so there were only 2.8 doctors on the 8-person registrar rota. This seems to have resolved, and additional measures put in place to shore up the resilience of staffing in the team, such as a new Advanced Practitioner.

Better staffing this year had alleviated a great deal of stress and worry for these doctors. However, we heard many ongoing frustrations with the way the service was run, and concern for patients. We were told that doctors are required in every patient episode of care in EPU (Early Pregnancy Unit), even for a normal, viable pregnancy. The view among doctors here was that this was poor use of the scant resource of their time and the service could be better organised and more streamlined protocols introduced. Their concern for patients was not about care provided, but about waiting times, which were described as “outrageous” on GAU (Gynaecology Assessment Unit). Mothers were said to come in at 2pm and routinely not be seen until well into the night shift.

The doctors in general practice training who were in these posts were satisfied that their curriculum was covered and they found it helpful to see the “flip side” of their GP referrals. However, a “disconnect” was described between the curriculum requirements and the rota. There was a specific point that they do not get enough time in clinics.

A foundation doctor was the first in such a post in the obstetrics and gynaecology unit of the trust, so there were inevitably some difficulties in getting started and they and their team knowing what the foundation doctor was able to take on. However, they were well supported, and had settled in and become a valued member of the team able to take on jobs from the ward round etc.

Middle-grade doctors in specialty training described getting exactly the experience they needed, preparing them for the next year of training. Higher specialty training was said to be a good fit for the unit as there were plenty of opportunities to develop the right skills to progress, however a similar criticism about the rota was levelled as previously: that “this is the right unit, but often I’m not in the right operating room for my training”.

We were told that rota coordination used to be fulfilled without medical input, and though we had heard that it had improved more recently, it was unclear to what extent there was clinical oversight of the rota in order to support doctors in training to achieve their learning outcomes and curriculum requirements. Even after any such improvements, it was still frustrating to the doctors that their rota would change frequently (“up to 2-3 times a day”)  and “at the last minute”  in spite of many of the rota changes being made due to “entirely predictable circumstances” such as leave that had been booked weeks before. This was said to be true of all levels of seniority.

Another specific gripe related to the rota was the process for accessing regional teaching. We were given to understand that currently doctors may miss regional teaching if they are on call. They are asked to apply for study leave for these. However, it was the view of the doctors present that a little coordination would allow the different cohorts for regional teaching to attend without needed to manage the rota gaps themselves.

There were many areas of investigation we asked the doctors about in which we heard no significant concerns. These included induction (which “prepared [the doctors] for the role”), handover (“the most effective part of the day”), supervision (“good trainers, even compared with other units”), local teaching, workplace-based assessments and incident reporting.

It was said that “not a single obs and gynae trainee” used the exception reporting system for working additional hours. Though they were told during induction that they should do this, they explained that they had never been shown how to and did not believe they had access to the system to do it.

We asked the doctors whether they would recommend their current post to a doctor in a similar position, and with the exception of one doctor in general practice training all agreed that that was a good place to work. The doctor who didn’t agree cited the GAU as the most difficult part of the job, stating that the last month had felt like they were just “holding the fort on this side of the hospital”. In contrast, another doctor in higher specialty training said this was the best unit they had worked in, and a foundation doctor called it their favourite rotation.

Educators

Our last session of the quality intervention was with the supervisors in obstetrics and gynaecology, with whom we were able to continue building a picture of the department which has clearly been improving as a place to work and train, and has plans and ambitions to continue to do so.

A very interesting development was learning that one of the signatories to the 28 July 2023 letter was now one of the new consultants in the obstetrics and gynaecology team, and able to share their perspective on the changes and ongoing challenges of the department.

We fed back the themes of our earlier conversation with the doctors in training and our previous concerns, and the consultants recognised and agreed with the summary: there is plenty of opportunity for good training, but doctors at various training grades are often unable to access it.

We also heard concerns from the perspective of the educators, such as late communication from the lead employer about reasonable adjustments and sickness (including mental health sickness), complexities around the rise in doctors in less than full time training, changing scope of practice for advanced practitioners, the reliance on the doctors in training for service provision, and the department’s own struggles to fix a rota schedule given the central medical staffing team’s ownership of the rota.

Cardiology

Five doctors in cardiology posts joined us and told us about their experience of the training posts they were in. These ranged from year one foundation doctors through to doctors in the fifth year of their cardiology specialty training. Unfortunately, the doctors we spoke to would not recommend this as a training department overall. Though there were many mitigating factors and positive elements to working and training here, the overwhelming consensus was that staffing shortages had too great an impact on the work to facilitate good learning, and even worried the doctors about continuity of care because different doctors would make new plans for patients every day.

We heard that the consultants were very accessible, and there was positive feedback about supervisors. For very early career doctors who would have appreciated time with registrars, this was said to be lacking, but the approachability of consultants and the interface with them in particular during ward rounds was said to make up for that. Doctors appreciated the “extremely knowledgeable consultant body” and benefited from those within it with an interest in teaching. It was said that not all cardiology consultants were excellent role models for communication skills and bedside manner, particularly in the context of equality, diversity and inclusion. The doctors told us they sometimes had to apologise to patients for the consultants not being clear in their plans and explain the plan again.

The general trust induction was overall well-received. The cardiology departmental induction, on the other hand, was described as “nearly non-existent”. Doctors were shown the handover room and given descriptions of documents that they then had to go away and find for themselves. However, work schedules were received in time and with no problems. IT and access to systems was adequate and the library was positively regarded.

Everyone was aware of the Datix system for incident reporting, and some were able to confirm they had immediate feedback from the system when using it, although this cohort perceived there to be “no formal learning from mistakes” (as a group) and no further feedback from the process after the initial acknowledgement. One doctor complained of staying late for half an hour after a night shift in order to fill out the form, making the point that the process can be onerous and that staffing levels make it impossible to submit incident reports while on shift due to the relentless workload.

Working relationships were described in positive terms overall, with pastoral support systems available to many. During this conversation, we learned that the doctors in internal medicine training felt like less of a cohort than other programmes. They felt that they didn’t have a distinct identity on the department either, being “used interchangeably with F1s or ACPs” and not being supported and pushed to meet their learning needs.

Supervision on a day-to-day level was experienced as mixed. The main issue that doctors had was a lack of feedback. Though formal and necessary feedback was provided to meet minimum requirements, these often had to be “chased down”, and informal feedback was not as forthcoming as the more junior medics would have liked. Positive reinforcement was said to be non-existent in the fast-paced ward environment. Doctors in training recognised the time pressures the consultants were under.

Formal teaching sessions were described as good quality. Lower grade doctors had teaching sessions rostered, whereas higher grades had to apply for study leave. Regional teaching included the simulation sessions, which were considered to be a strength of the programme.

It was also difficult for supervisors to stay abreast of the new curriculum requirements, particularly the General Internal Medicine (GIM) component. Some educational supervisors were described as unable to provide helpful input.

It was notable that the ‘Junior Doctor Forum’ was positively regarded, noting good representation from the trust executive body, and clear governance of minutes, actions and following up on previous items.

It became clear from this discussion that there were many positive aspects of the training in this unit – indeed the opinion of the panel was that this had the potential to be a great unit for cardiology training. The main factor letting it down and preventing the department from achieving this potential was the staffing shortage that was so acutely felt by the doctors in training.

Educators

Later in the day in a separate session, we spoke with a small group of trainers, educators and supervisors in cardiology and shared some of the feedback we had heard and asked them about their view of education governance and provision in the trust. This was a valuable session which highlighted to us how separate the consultant body felt from the rota which was the subject of much concern by their juniors.

The consultants felt they had little influence over the rota, and would strongly support the idea of revising the rota governance. We asked about the lack of a cardiology departmental induction and found no one with ownership of this area. We questioned them on job planning and we told it is a “bit of a mess”. We were disheartened to learn that a well-regarded educator had stepped back from the supervisory role due to the unsustainable workplace pressures. We did not get a clear answer as to the role of a trust specialty training lead (TSTL) for cardiology, and whether there was one. This was later clarified by the trust to be a vacant post covered by one of the clinical directors within the trust.

A positive change we heard about was the trainers’ views on raising concerns – we heard there used to be a culture of not raising concerns and over the years that has changed to feel more like an open culture where concerns can be safely raised.

Emergency medicine

We were joined by nine doctors in emergency medicine training. Starting at the beginning of their placement, we were told about inductions that were good and met expectations, with practical details such as system logins handled well, and rotas provided in good time ahead of starting.

Doctors in higher specialty training told us that self-rostering was being rolled out in some areas, and that the meetings earlier in the year to set up and support good rota governance were positive and successful – they felt engaged and listened to.

Learning experience on the job was said to be good and staffing compared favourably to other units the doctors had worked in, allowing the department to release doctors to carry out procedures, for example. The quality of this experience did depend on how proactive one is, according to these doctors. They found it difficult to coordinate with the consultants at times, as doctors in training will only see their own rota and not the consultants’ rota. It was suggested that sight of the consultant rota would make this easier. Doctors not in emergency medicine specialty training (e.g. GP or Acute Care Common Stem [ACCS] pathways) described difficulties getting Workplace-Based Assessments, but no problems for anyone with case studies and procedures.

Formal learning was reported to be good quality, with most doctors we spoke to able to go in-house training on Wednesday, though higher specialty doctors had relatively low attendance at their own “journal club” even though this was theoretically protected. ACCS pathway doctors were released for their regional teaching, which was highly praised. Higher specialty doctors in emergency medicine were also released for their regional teaching, though ACCS and GP told us they had to book study leave to attend these and sometimes struggled to do so. Simulation training was regionally programmed, and the doctors were aware of a new suite for simulation that was soon to be used.

Incident reporting processes were described to us and everyone present had used the system. We were informed one can “opt into” feedback from incidents and that feedback from them does come through.

We briefly asked about these doctors’ access to library support, IT, space and other such practical matters, and heard that all of the above were adequate. Some doctors told us they had been supported to complete an audit.

All had been allocated and met with their educational supervisor. We were told of an example of a doctor in a specific area who felt they had poor supervision, but after raising it with their educational supervisor there were changes made to support – a good example of the responsiveness of the department to local concerns.

We were told of good working relationships across the board: between different grades of doctors in training, between doctors in training and consultants, between emergency medicine and other specialties, and between medics and other professions including nurses. Some doctors had had experience of “difficult people” but said that this was raised and appropriately dealt with.

It is striking that all of the doctors we interviewed stated that they would recommend this post and placement. For all the concerns raised, there is a universally felt supportive environment in which doctors in training at all levels were safely exposed to learning opportunities on the job. However, at the end of the discussion when we asked about the most important issue there was another consensus: rota issues.

Educators

Our separate meeting with the emergency department consultants was encouraging. All of those present were educators, all with training. Job planning sounded sensible. There appeared to be good systems for appraisals, continuous professional development (including away days), and a robust approach to equality, diversity and inclusion. Good support for doctors in training requiring extra support, including international medical graduates. Most critically, we heard of some clinicians (notably the college tutor) working hard to stay involved in rota governance and we were updated on the latest plans to bring in self-rostering.

Areas for improvement

Mandatory requirements

Recommendations

• Review policy requiring doctor contact for every contact on the EPU (Early Pregnancy Unit). Doctors feel their input is not necessary or helpful for normal, viable pregnancies, for example.

Report approval

Report completed by: Zander Zambas, Quality Support Manager
Review lead: David Ross, Associate Dean
Date approved by review lead: 22 January 2025

NHS England authorised signature: Raghu Paranthaman, Deputy Dean
Date authorised: 23 January 2025

Final report submitted to organisation: 23 January 2025

Publication reference: PRN01548