The Thames Valley Quality Team has a responsibility for ensuring that clinical learning environments meet quality standards for education and training set by NHS England and the GMC. This process is managed under the Quality Strategy and 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 Intensive Support Framework.
Over the past year (August 2023 to July 2024) 35 risks were managed on the risk register. Four of these were of a significant concern and were therefore reported to national and regional teams within NHSE-WTE and to the GMC. These were:
- Trauma & Orthopaedics at Buckinghamshire Healthcare NHS Trust (closed from the significant concerns register in March 2024 but remains open on the Thames Valley risk register – see further detail below).
- Ophthalmology at Oxford University Hospitals NHS Foundation Trust (closed March 2024 from the significant concerns register but remains open on the Thames Valley risk register; this has subsequently been escalated to reflect ongoing concerns).
- Paediatrics at Milton Keynes University Hospital NHS Foundation Trust (closed January 2024 from the significant concerns register and closed from the Thames Valley risk register September 2024 – see further detail below)
- Cardiology at Buckinghamshire Healthcare NHS Trust (remains on significant concerns register – see further detail below).
- At the time of writing, Histopathology at Royal Berkshire Hospital has been added to the significant concerns register following concerns raised through the School of Histopathology.
As a result of actions taken to resolve concerns, 22 risks were closed. At the time of writing, 26 risks remained open on the Thames Valley risk register which include 12 new risks arising from the NTS 2024 and one new risk arising from the School of Histopathology quality review meeting.
The list below comprises the main training issues that arose from the 2023 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 |
| Trauma & Orthopaedics – Foundation Training | NTS 2022 & direct feedback from foundation doctors in training in February 2023 | Concerns regarding supervision and support for the medical needs of surgical patients, rota issues, lack of educational opportunities and teaching, and overrunning of the morning handover/trauma meeting delaying release of doctors in training (DiT). A Trust action plan followed which included changes to the induction, rota development, increases in recruitment and improvements to the teaching programme. Subsequently, a quality visit to the Trust took place in October 2023 and found considerable improvements in most areas but there remained a lack of medical supervision on the wards. | This was reported on in last year’s report. It remained on the risk register for monitoring the provision of senior medical cover on the wards. Assurances have been given that Orthopaedic and Orthogeriatric cover has been enhanced. The NTS 2024 results showed significant improvement for all grades and, for higher training, there were four positive outliers. |
| Cardiology | NTS 2023 / School of Medicine | Multiple red outliers in GMC survey including workload, clinical and educational supervision, practical experience and rota. There has since been multiple red outliers in the NTS 2024. | Trust implemented actions to address the 2023 NTS outliers but there was a subsequent escalation of concerns via the School of Medicine, in particular regarding supervision (with concerns for patient / trainee safety), incivility, lack of education and training, rota challenges and staffing levels. An Urgent Risk Review took place at the Trust in July 2024. A new education lead had been appointed and improvements to education and training had begun. Workforce numbers have since increased and Consultant appointments have been made. Immediate Mandatory Requirements for supervision and support were met by the Trust satisfactorily and there was positive feedback from DiT supporting this. Further mandatory requirements were set for increasing education and training time by improving the rota/staffing, raising concerns, incivility and handover and the Trust continues to implement its action plan to address these. The issues remain on the significant concerns risk register and focus groups with the new cohort of doctors in training have been arranged for February 2025. |
Frimley Health NHS Foundation Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| Anaesthetics | NTS 2022 | Several negative outliers in the GMC survey included teaching and supportive environment, which appeared to be the main problem area. A Trust action plan followed which included changes to the regional (involving the School of Anaesthetics) and local teaching provision. Subsequently, a focus group with Doctors in Training (DiT) was held to assess progress. Findings showed that education and training had improved. However, there were concerns reported around incivility and the confidence to raise training concerns and mandatory requirements were made around these two issues. | This was reported on in last year’s report. It remained on the risk register for monitoring the outstanding issues of incivility and the confidence to raise training concerns. The risk was formally reviewed by the Quality Committee in Summer 2024. Significant progress had been made towards addressing the cultural issues with a trainee representative system and junior doctor forums. There was also considerable progress made to encourage DiT to raise concerns, offering numerous opportunities to do this and plans to continue seeking regular feedback. A new College Tutor was in post. The risk was closed in June 2024. |
| General Surgery | NTS 2023 | Nine red outliers in the GMC survey 2023 including rota design (concerns that the rota did not optimise education and training), induction (concerns that DiT did not get all the information they needed), and adequate experience (some concerns that DiT will not acquire the competencies they needed). | Following an initial response from the Trust to the outliers, the Quality Committee reviewed a formal update at its meeting in March 2024. There was a detailed actions plan covering the main issues of teaching and attending theatre lists. There had also been a change in surgical tutor. The issue remained on the risk register for monitoring and the GMC NTS 2024 showed significant improvement. During the review of this risk at the annual School of Surgery quality review meeting in November 2024, there was agreement to close the risk. |
Oxford Health NHS Foundation Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| General Psychiatry, Warneford Hospital | NTS 2023 | Multiple red outliers in the GMC survey 2023 – supportive environment (some reports of rudeness and incivility) and workload were the main areas of concern. | The Trust organised a stakeholder meeting between the Head of School, DME, TPDs and doctors in training. Exception reports were reviewed and the source of the workload issues were identified and adjustments made. Source of the incivility was also identified and addressed appropriately. The NTS 2024 was significantly improved and included two (green) positive outliers. The risk was reviewed in the annual School of Psychiatry quality review meeting in November 2024 where it was heard that recruitment had eased workload pressures. The risk was subsequently closed. |
Milton Keynes University Hospitals NHS Foundation Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| Paediatrics | NTS 2022 | Heavy workloads, staffing gaps and insufficient workforce numbers impacted capacity for training, chiefly access to teaching and learning opportunities. Overrunning of the morning handover and rudeness and incivility. The Trust responded with an action plan and a quality review took place at the Trust in January 2023. Subsequent reviews followed in 2023 & 2024, and while improvements to training continued including a new monthly teaching programme, instances of incivility were still occurring and a reluctance to report these. The risk was subsequently downgraded and removed from the significant concerns register. Issues pertaining to incivility and reporting mechanisms continued to be monitored on the local risk register. | This was reported on in last year’s report. It remained on the risk register for monitoring issues pertaining to incivility and reporting mechanisms. Further feedback showed improvements to the culture with fewer incidents of incivility and more confidence that these could be reported and would be dealt with. Among actions taken to address the issues were: A focus on handover with greater effort to complete handover within schedule time. Regular auditing took place to monitor progress. Formal teaching sessions were better protected with a focus on releasing doctors for sessions. A change of clinical and educational leadership and a drive to change the culture to encourage reporting of concerns. The risk was closed in September 2024. |
Oxford University Hospitals NHS Foundation Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| Endocrinology and diabetes mellitus | NTS 2023 | Several red outliers with rota design, clinical supervision, workload, supportive environment and access to teaching as the main areas of concern. | Trust explored the outliers and responded with a comprehensive action plan. This included: Actions to reduce workload such as reducing clinic numbers and a service moving to Consultant delivery. A review and monitoring of clinical supervision. A review of the rota with registrars. Further investigation into supportive environment concerns. Re-arranging of clinics to allow better access to teaching. Positive feedback was reviewed and the risk was closed March 2024. NB. A smaller number of outliers appeared in NTS 2024 and will be added to the risk register for monitoring. |
| Haematology, John Radcliffe Hospital and Churchill Hospital | NTS 2022 and 2023 | Several red outliers across both sites including rota design, study leave, induction, supportive environment (staff treated fairly). | Trust responded with a comprehensive action to plan to address the issues raised. A further survey was conducted with doctors in training to gain more in-depth feedback. Actions included: Introduction of a training committee. Rota re-design. Defining of job roles. Work to address the culture included an external facilitator to enhance professional behaviours and communication. Induction was reviewed and monitored for improvement. Additional staffing, including Consultant expansion which improved supervision and provision of education and training. The NTS 2024 showed significant improvement. Risk closed December 2024. |
Royal Berkshire NHS Foundation Trust
| Learning environment | Source of concern | Summary of concern | Action taken/outcome |
| Trauma & Orthopaedics | NTS 2023 | Multiple red outliers in the GMC survey with most negativity against induction, local teaching, reporting systems, rota design, study leave, and supportive environment. | The Trust explored the outliers and responded with an action plan to address the issues raised. A comprehensive update on progress and supporting evidence was reviewed by the Quality Committee in March 2024. Local training forums had been set up and were enabling change. There had been further Consultant recruitment, improved consultant job plans to increase support and the rota was fully staffed. While improvements were still being made and embedded, the risk was closed due to the introduction of the training forums which would continue to respond to issues. The risk was closed in March 2024. There were fewer outliers in the NTS 2024 showing continued improvement. |