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. Risks are graded using the NHSE Intensive Support Framework.
Over the past year (August 2021 to July 2022) 36 risks were managed on the risk register. As a result of actions taken to resolve concerns, 20 risks were closed and 25 risks remain open on the Thames Valley risk register which include 9 new risks arising from the NTS 2022. Five risks were of a significant concern and were therefore reported to NHSE Executive and to the GMC.
The list below comprises the main training issues that arose from the 2021 NTS or via other governance routes and the actions taken.
Buckinghamshire Healthcare NHS Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| Cardiology (Foundation training) | Director of Medical Education, Apr 2021 | Concerns raised regarding supportive environment for foundation doctors. | Trust commissioned an external report and developed an action plan. Subsequent feedback from Foundation doctors indicated that the issues had been resolved. Foundation doctors were also submitting exception reports. The risk was closed in April 2022. |
| Histopathology | NTS 2021/ Head of School | Significant pressure due to increased workload, gaps in consultant numbers and difficulties recruiting. Significant challenges to sustain high quality training especially for the ST1 School which was located at Wycombe Hospital until August 2022. | The ST1 school moved to another location in the Thames Valley region at the beginning of August 2022; some training (above ST1) remains at Wycombe Hospital but with an improved trainee / trainer ratio. Multiple red outliers in NTS 2022. The Head of School has also flagged concerns regarding workload and supervision for the training that remains at this hospital and therefore the risk will remain on the risk register at its current level for monitoring/further discussion. |
Oxford University Hospitals NHS Foundation Trust
| Learning Environment | Source of Concern | Summary of Concern | Action taken/outcome |
| Paediatrics Neonatal Intensive Care Unit | Trainee Advisory Committee, Dec 2020 | Departmental culture including behaviours, multidisciplinary team working/ learning and reporting of concerns. Support and supervision for learners to acquire essential skills. Intensity of workload and the impact of this on education and training and learner wellbeing. | On reviewing findings from focus groups held in Autumn 2021, the risk was escalated to Category 3 – Major Concerns – on the Intensive Support Framework. A quality review report identified a number of mandatory requirements and recommendations. This included actions around improving access to teaching, and ability to leave on time, maximising opportunities to gain practical skills and procedures, and improving the culture. Over the past year, the Trust has engaged well in improving the learning environment. Chiefly, it has invested in initiatives to improve the cultural issues. The risk will continue to be monitored while the action plan is fully implemented and embedded and trainees are reporting higher levels of satisfaction. |
| Clinical Oncology Medical Oncology | NTS 2017 & subsequent NTS | Current concerns are focused around the heavy on-call rota arrangements impacting education and training. | A Learner / educator meeting was held in 2022 to follow up progress from the original Quality Visit in December 2019. Trainees report ongoing concerns regarding the amount of on-call work which is limiting time in training, particularly clinic access. The department is looking at ways to increase workforce numbers. The risk will continue to be monitored on the risk register. |
| Ophthalmology | School of Ophthalmology July 2021 | Limited opportunities to access theatres for ophthalmology trainees for all sub-specialties but most concern about the amount of cataract surgery available for training purposes. | The Head of School for Ophthalmology continues to monitor case numbers closely. The risk was escalated to Category 2 – Significant Concerns – on the Intensive Support Framework. |
| Renal Medicine | School of Medicine, Nov 2020 & NTS | Trainees moved to resident on-call reducing daytime training opportunities. | Impact monitoring by Head of School. Trainees are encouraged to exception report any missed educational activities. Remains in risk register for monitoring. |
| Neurosurgery – Foundation training | Existing risk register item | Risk of high workload levels which may impact the quality of the learning environment by 1. missed training opportunities and experience such as access to theatres, clinics, teaching attendance within scheduled hours and without interruption from bleeps. 2. workloads that are admin heavy and with little educational value. 3. trainees working beyond their rostered hours 4. effects on trainee well-being. | This long-standing risk register item was previously under GMC Enhanced Monitoring. It remained on the risk register over the past year to monitor sustainability following significant improvements which were made to the learning experience for foundation doctors. After positive feedback from several cohorts of foundation doctors, the risk was closed in August 2022. At the time of writing, the quality team were notified of continuing workforce challenges which are currently being explored to assess the impact on education and training. |
Royal Berkshire NHS Foundation Trust
| Learning Environment | Source of Concern | Summary of Concern | Action taken/outcome |
| Haematology | NTS 2021 | Multiple red outliers for overall satisfaction, workload, supportive environment and handover. Outside of the survey, concerns were also raised about the culture within the department. | Issues were acknowledged by the Trust and there was good engagement by the department and trainees with support from HR and the DME. A comprehensive action plan was developed to address the training concerns and the cultural issues. The department has continued to engage with trainees and regularly meet to discuss the issues. Although further red outliers were flagged in the NTS 2022 for Workload, Induction, Feedback and Teaching, Local Teaching appeared to be the main concern. These have been responded to with a detailed action plan together with support from the Training Programme Director and ongoing monitoring. In addition, there has since been positive feedback from current trainees. |
| Histopathology | Head of School/TAC in 2021 | Significant Consultant vacancies and difficulties recruiting had led to workloads with excessive amounts of service work and little education such as cut ups. More recently, consultant numbers have continued to fall leaving training to a small number of educational supervisors. | Notwithstanding the shortages in educators, the training remains good quality. Changes were made to reduce excess ‘cut up’ work and consideration is given to maximising learning opportunities. Trainee feedback has been positive despite the challenges, describing a ‘good culture for learning’. The department has plans for recruitment but the wider concern about Consultant shortages nationally, applying to posts in District General Hospitals, has been escalated. In addition, the Trust is establishing the role of the Biomedical Scientist to enhance their multi-professional workforce. |
| Cardiology (all grades/programmes) | NTS 2021 | Red outliers for Overall satisfaction, workload, handover, local teaching, regional teaching, study leave and rota design. Plus multiple pink flags. | Staffing issues and COVID redeployment impacted workload and leave approvals. A robust Trust action plan included the introduction of educational governance meetings, an improved online induction, an increase in Educational Supervisors, a revamped teaching programme, additional doctors, a revised rota allowing teaching time and clinic access, and handover guidance within the staff handbook. NTS 2022 results were positive with many positive (green) outliers. The risk was closed in August 2022 following discussion with the DME. |
Frimley Health NHS Foundation Trust
| Learning Environment | Source of Concern | Summary of Concern | Action taken/outcome |
| Acute/General Internal Medicine | NTS 2021 | Multiple red outliers across many acute medicine specialties affecting higher specialty and core medicine doctors, GP and foundation doctors. The pandemic adversely affected all acute medicine areas which increased and intensified workload | Trust actions included increasing staffing at weekends and at night, adjustments to the handover process, and improvements to departmental inductions. Increased use of simulation and practical procedures to expand learning opportunities. The Trust’s educational governance meetings continued to provide opportunities for trainees to raise concerns and for these to be addressed. No further concerns were raised and the risk was closed in April 2022. Results from the NTS 2022 for these areas were much improved. |
| 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. The risk was reviewed in early 2022 after positive feedback had been received for higher training through the Trust’s own governance processes. The risk was closed with core surgical training being explored as part of a wider regional investigation. |
Milton Keynes University Hospitals NHS Foundation Trust
| Learning Environment | Source of Concern | Summary of Concern | Action taken/outcome |
| Emergency Medicine | NTS 2021 | Red outliers for Teamwork and Supportive Environment | Focus groups held in June 2022 revealed no significant training concerns. Inter-departmental teamworking received positive feedback. There were some issues raised by trainees about engagement in teaching from the wider Consultant body but this was being addressed. NTS 2022 results were much improved. |
Central North West London NHS Foundation Trust (Milton Keynes sites)
| Learning Environment | Source of Concern | Summary of Concern | Action taken/outcome |
| Core Psychiatry Training at the Campbell Centre | NTS 2021 | Multiple red and pink flags in the NTS. Main concerns were around handover and rota design which trainees reported as not optimising education opportunities. | The Trust initiated a quality improvement project to improve trainee satisfaction. Trainees were involved in making improvements to handover and have subsequently agreed this has been resolved satisfactorily. Trainees have also given positive feedback regarding local teaching which is now protected. Staffing numbers have also increased which has increased learning opportunities. |