The Thames Valley Quality Team has a responsibility for ensuring that clinical learning environments meet NHSE and professional regulator standards for quality. This process is managed under the NHSE Quality Framework, and is informed by the risk register. The risk register is multi-professional, but most of the risks are medical due to arrangements between Local Education Providers and the universities for managing quality concerns in non-medical education.
Over the past two year (August 2019 to July 2021) 108 risks (a small number of these were in non-medical education, e.g. in Pharmacy and Library services) were managed on the risk register. As a result of actions taken to resolve concerns, 62 risks were closed.
The list below comprises the main training issues managed since 2019 NTS and the actions taken. The full NTS did not run in 2020, therefore, the quality team was reliant on other educational governance processes and sources to monitor the quality of the clinical learning environment.
Buckinghamshire Healthcare NHS Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| Emergency Medicine | School of Emergency Medicine / Trainee Advisory Committee, May 2020 | Concerns regarding supervision, and ability to raise concerns. | The Trust organised an internal investigation and action plan drawn up. TAC feedback December 2020 suggested improvements made, and this continued when QC reviewed in 2021. Risk grading reduced; ongoing QT monitoring in place. |
| Cardiology Medicine on-call rota | Director of Medical Education, Oct 2018 | Higher trainees concerned about supervision when covering cardiology. Rota and workload issues and supportive environment concerns | Trust action plan in place. Deanery Visit in February 2019 gave recommendations, with a follow-up visit in December suggested improvements and risk score reduced, monitoring ongoing. |
| Cardiology (Foundation training) | Director of Medical Education, Apr 2021 | New concerns raised in monitoring of risk issue above; regarding supportive environment for foundation doctors. | Trust has commissioned an external report and is developing an action plan. |
Royal Berkshire NHS Foundation Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| Ophthalmology | NTS 2019 | Issues regarding handovers of clinical care, workload affecting training opportunities, induction and rota management | A Learner educator visit undertaken in January 2020 made recommendations. Follow up visits and progress reviews against these followed. Actions included establishing a faculty group, increasing ES numbers, enhancing teaching. Despite COVID impact, sustained improvements reported by trainees resulted in risk being closed in June 2021. |
Oxford University Hospitals NHS Foundation Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| Neurosurgery – Foundation and Specialty training | Existing risk register item | Specialty training: concerns around progression from ST1-4, access to spinal surgery, workload, access to theatre, and handover. Foundation training: Workload (including work patterns), access to training opportunities/ teaching, educational supervision | Triggered visits, and follow up visits, made requirements and recommendations. This included support from NHSE workforce transformation team and pump priming monies. The recommendations were actioned by Trust and School. For higher training, the improvements to training were sustained and removed from Enhanced monitoring and Risk register December 2020. Foundation training: Changes including workforce increase, additional input into teaching supervision, changes to handover and team allocation. removed from Enhanced monitoring, risk downgraded. Ongoing monitoring through TAC and FTPD. |
| Clinical Oncology | NTS 2017 | Initial activity around educational and clinical supervision, and teaching programme changes resulted in NTS 2018 showed improvement. NTS 2019 showed significant deterioration. Significant element was concern over involvement in hospital at night rota (shared concerns with Medical Oncology). Ongoing concerns through re-visits regarding: workload, especially on-call, some concerns regarding clinics in Medical Oncology, and trainee voice being heard. | Quality Visit in December 2019. Trust reconfigured hospital at night rota. On call rota for Oncology re-configured and arrangements reviewed. Trainee feedback at the Quality Committee in May 2021 heard ongoing concerns regarding rota arrangements impacting training. NTS 2021 showed improved results, but still ‘red flags’. A Learner educator meeting will be held in 2022. |
| Ophthalmology | NTS 2018 | High workload (including in emergency eye clinic) affecting ability to access cataract surgery and teaching. Concerns about access to induction. Concerns around supportive environment, and trainee voice being heard. | Learner educator meeting (‘visit’) undertaken, and recommendations made, in June 2019. These included setting up faculty /trainee group, changes to teaching and induction, changes to eye casualty cover, and access to surgery. The Trust implemented these, and this risk was closed in June 2021 (with monitoring of cataract numbers ongoing) |
| Renal Medicine | School of Medicine, Nov 2020 | Trainees moved to resident on-call; issues with adequate accommodation, the impact on training opportunities. | DME has ensured on-call room provision. Impact monitoring by HoS. Rota currently undergoing benchmarking. |
| Anaesthetics | NTS 2018 | ST3 year/ICU: specifically achieving curriculum coverage within placements as organised. Workload and supportive environment issues. | Rotations changed to support ST3 year requirements (ahead of new curriculum). Staffing concerns addressed with staffing increases. Supportive environment issues addressed by Trust. Removed from Risk Register after positive trainee feedback June 2021. |
| Clinical Radiology | NTS 2017 | Concerns around teamwork, supportive learning environment and workload. | Extensive initiatives to address issues including additional resources, improved facilities, time for educators, revamped teaching programme and increased trainee engagement. Risk closed October 2019. |
| Paediatrics Neonatal | Trainee Advisory Committee, Dec 2020 | Concerns around access to clinical cases to facilitate training, especially critical care skills Concerns around inter-disciplinary working and behaviours Concerns around workload and rota | An action plan by School of Paediatrics in place, and actions by department to address these issues (such as increasing staffing levels, ‘Civility’ training). A virtual visit was performed and progress reviewed at the Quality Committee. In Autumn 2021 a series of focus groups took place to further clarify issues and progress to date. |
Frimley Health NHS Foundation Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| O&G | NTS 2018 | Concerns from 2016 regarding workload addressed previously. Concerns from 2018 related to: clarity of pathways and guidance, workload and rota issues resulting in lack of educational opportunities. Behaviours and departmental cultural aspects. | A series of QC visits was undertaken in 2020/1, and requirements and recommendations made. The department and the Trust invested heavily in staffing, and interventions to address cultural issues. Significant investment in educational structures and governance by Trust, and activity within the department to enhance the learning experience and confidence to speak up. Significant and sustainable improvements made and it was removed from risk register and reporting in November 2021. |
| General Surgery | NTS 2018 | Concerns around lack of access to theatre, clinic workload. 2019 survey also identified workload, handover and rota design as concerns. | Trust implemented changes to clinics for trainees, increased support and clinical staff numbers. Significant COVID impact on theatre access and re-deployment. To be reviewed in early 2022. |
| Respiratory Medicine | School of Medicine, Dec 2020 | Concerns around workload and supportive environment | Acknowledged significant COVID impact. Changes to rota, and working arrangements, implemented increase in staffing. Trust and School have monitored, and ongoing monitoring in place. |
Milton Keynes University Hospital NHS Foundation Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| O&G | NTS 2018 & 2019 | Issues related to behaviour of some staff, consistency of clinical supervision and support, clarity of pathways and guidance, workload/ rota issues, handover and raising concerns. | A series of QC visits and progress reviews was undertaken between 2019-2021, and requirements and recommendations made. The department and the Trust addressed behavioural issues. Significant investment in educational activities, within the department to enhance the learning experience, including establishing and iteratively improving a process to hear trainee voice. Significant improvements demonstrated in learning experience, and removed from risk register and reporting in June 2021 |
| Emergency Medicine | NTS 2019 | High workload. Concerns around provision of teaching, teamwork and supervision. | Changes to teaching provision, including release of FY2 to core teaching. Increase in Consultant numbers, and divisional intervention on inter-departmental working. A visit took place in October 2020 (delayed due to COVID). Trainee feedback was positive, with a few suggestions given. Teamworking and supervision reported as much improved. Removed from risk register. New concerns have been flagged in late 2021 – see section 6ii. |