Core Surgery Level 2 visit report


Local office name: Health Education England, working across the South West

Organisation under review: Northern Devon Healthcare NHS Trust

Placements reviewed: Core Surgery

Date of Review: Tuesday 2nd May 2017



Reason for Review

Feedback through ARCP process

No. of Learners met


No. of Supervisors/Mentors met


Other Staff members met

Director of Medical Education

Duration of review

2 hours

Intelligence sources seen prior to review

ARCP feedback



Name Job Title
Dr Mark Westwood  Head of School for Surgery
Mr Neil Squires Specialty Training Manager
Ms Jane Bunce Quality Manager
Ms Gemma Agar Quality Support Manager



The School of Surgery, led by the Head of School, visited Northern Devon Healthcare NHS Trust in May 2017 following receipt of adverse feedback regarding the Core Surgery programme.  The panel met with the current CT1 in post.  During the meeting a number of good learning opportunities were highlighted along with acknowledgement of good support and a positive experience.  It was evident from meeting the trainers that at the time of the visit they are committed to delivering a high quality training experience and had already addressed a number of areas of concern.



Outcome report completed by (name) Ms Jane Bunce
Chair's signature -
Date signed -
HEE authorised signature Dr Martin Davis 
Date signed 23rd October 2017 
Date submitted to organisation 23rd October 2017



Job title Name
Director of Medical Education  Dr Guy Rousseau 
Supervisor/Consultant Urologist Dr Eng Ong
Medical Education Manager Caroline Rawlings 



Score prior to review Likelihood 4 - Impact 3 = 12 AMBER 
Proposed scores following review  Likelihood 2 - Impact 3 = 6 AMBER



Any concerns listed will be monitored by the organisation. It is the organisation's responsibility to investigate/resolve.

Were any patient/learner safety concerns raised at this review?  NO 



Recommendations are a proposal as to the best course of action.


Related Domain(s) and Standard(s)

GMC Theme   1.Learning Environment and Culture

HEE Standard 1.Learning Environment and Culture

Summary of findings
  1. General Surgery to be reviewed in due course following relocation of Vascular and Breast Surgery services.
  2. Handover to be reviewed in September 2017 to assess success of re-badging SAU ward.



Learning environment/


Good Practice

Related Domain(s) &


Surgery 1. Dedicated Urology teaching list and clinic

GMC 1,3

HEE 1,3

Surgery 2. Monthly departmental meeting used as teaching opportunity

GMC 1,3

HEE 1,3

Surgery 3. Dedicated hernia training list

GMC 1,3

HEE 1,3




The visiting panel met with the Core Surgical Trainee (CT1) in post at the Trust.  The trainee had completed 6 months in Urology and was currently working in Colorectal Surgery.


Induction: The trainee confirmed there was an adequate Trust and departmental induction.  The trainee was also able to meet with the allocated ES early in the placement.


Teaching and experience: Dedicated Urology teaching list on Thursday mornings and clinic on Friday mornings which provide good teaching opportunities.  There is a biopsy list on a Thursday morning with a reduced number of patients to allow time for practice. 

The trainee had his own clinic with a good mix of patients.  There was opportunity to discuss the management plan and this was regarding as a good learning opportunity. 

The trainee believed that the ward work had improved since finishing his Urology post due to additional staff being in place.  The hard work of Mr Ong in securing the improved staffing was acknowledged. The CT1 reported the senior review of patients as being well supported at consultant level and good consultant availability via mobile phone, as necessary. 

The trainee reported having been able to do teaching himself at the monthly departmental meeting.

The CT1 had experienced good access to CEPOD and described the Colorectal consultant as ‘fantastic’.  During his time with the Trust, he has often acted as the first assistant in theatre.  The hernia training list was also highlighted as a good learning opportunity.

Teaching was generally on the job and patient based and he had been able to attend the majority of regional teaching provided.  It was recognised by the trainee that the consultant body had all tried to do their best for him.


Surgical on call and handover:  The Registrar would accompany the trainee on the ward round to review in-patient referrals.  Good support was provided by phlebotomists and the trainee was only required to do the more difficult catheters. 

The Medical Registrar provided good support with very sick patients and the trainee reported being able to contact the on call team as necessary.  The Anaesthetic team was described as accessible and friendly.

General Surgery on calls were described as well supported and intensity of workload is manageable with an average of 10 referrals.  Handover takes place with the Consultant and Registrar in the morning and with the Registrar in the evening.


Assessments:  Having WBAs completed was described as normally quite good with Consultants being happy to complete them.  The trainee’s log book was up to date and he had been able to complete a reasonable spread of operations.  Trainee felt very well supported and had not worked outside their level of competence.


Audit / Study leave:  Trainee reported being encouraged to complete an audit on theatre efficiency and was well supported by Mr Misra.  No concerns raised regarding access to study leave for exams, which included the opportunity to attend two courses.


Working relationships: Trainee described his placements as being a positive experience.  Being the only trainee has meant that the trainee has had access to a good variety of cases, including some more complicated surgeries whilst in colorectal, without having to compete with others for experience, thus keeping his numbers up.  The support received has had a positive effect on his confidence.


The trainee had not witnessed any bullying or undermining although theatre staff can provide abrupt advice but this was not portrayed as a significant concern.

The trainee confirmed that he would be happy to remain with the Trust for two years and felt there was sufficient training opportunity other than in Upper GI.



It was recognised at the start of the meeting with the trainers that the trainee had portrayed a very positive picture of the training environment and they were asked to describe how they had achieved that.

  • Structural changes had been made to the rota.  Whilst at times the rota can be more intense than previously, the revised rota also blocks time off which was viewed as an improvement.  Core trainees had previously been on-call on their own, but there were now two doctors on the rota.
  • A ward has been rebadged as an SAU which means that the on-call team are now in one location, rather than on six different wards.  This has improved handover.
  • The consultant job plan now includes time for ward rounds and allows the consultants to offer more support and learning opportunities to trainees due to the structure of the day.
  • Improved facilities are available in the SIM centre.
  • Vascular cases are no longer being dealt with at the Trust and breast surgery is likely to move to the RD&E.  As a consequence, general surgery is now busier with 3-4 theatre lists and there are more opportunities for trainee experience.
  • Urology was described as stable but with good opportunities for trainee doctors.
  • The consultant body had stabilised and the commitment of trainers was recognised as having made a positive difference.  One permanent appointment still needs to be made in urology, but a long term locum is in post in the meantime.

The additional staffing described by the trainee (increase from two to three junior doctors) will revert back to two in August.  The supervisors were aware of the need to keep an eye on the balance of service versus training and highlighted that a physician associate (PA) was being employed in Urology from January 2018.  In total four PAs would be joining the Trust from January to help with service demands with two being recruited to Surgery in addition to the one in Urology.


In addition to the points raised above, it was explained that the new rota also allows more flexibility in terms of study leave as it can absorb people being away.  The trainers also explained how the postgraduate team take a flexible approach to study leave budget as trainees needs do not always fit within the amount assigned to each individual.


Conversion rates were discussed and the trainers explained why they did not have any concerns in this area:

  • One trainee chose to not progress within surgery and secured a training number in Clinical Radiology; this was a pre-existing interest
  • Two trainees chose to move in to research (one of these trainees was offered an interview for the ST in Trauma & Orthopaedics but subsequently decided to do a year of research first)
  • One trainee who experienced problems, had been detected by the team early and offered appropriate support, but had subsequently chosen to leave the programme
  • No problems have been highlighted through MRCS
  • As a general rule, trainees who choose to train in North Devon can be less career driven than trainees choosing, for instance, to go to Derriford.  Therefore they felt it was hard to compare conversion rates with those of other trusts.

The visiting team explained how the Trust would not have a trainee for August as the national recruitment process had not recruited to the post.  There was no intention not to recruit to the post for 2018.  Whilst this year’s vacancy could be filled by a trainee requiring additional time, it was explained that this was an unlikely scenario.


The training team explained that they were committed to providing high quality training but felt that they were lacking opportunity at the moment.  It was felt that the Trust has capacity to support two trainees in CST and the trainers requested consideration be given to pairing the ND post with a popular Trust such as RD&E to increase the likelihood of filling it.


Date of report: 12th May 2017

Author: Ms Jane Bunce

Job Title: Quality Manager