Trauma and Orthopaedic Surgery - Level 2 visit report


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

Organisation under review: Plymouth Hospitals NHS Trust

Placements reviewed: Trauma and Orthopaedic Surgery

Date of Review: 26th January 2018



Reason for Review

Feedback from ARCP, JCST survey, GMC NTS, Quality Panels

No. of Learners met

4 (STR Level)

No. of Supervisors/Mentors met           


Other Staff members met

Management Teams - T&O

Duration of review

 Half Day

Intelligence sources seen prior to review

Log book data

Quality Panel Report 2016

2017 GMC NTS results




Name Job Title
Dr Martin Davis Head of Quality, HEE (Chair)
Lt. Col Michael Butler TPD
Maria Harding Lay Representative
Sophie Rose Quality Support Administrator



A triggered visit was carried out in response to concerns raised regarding the lack of training opportunities and inappropriate tasks undertaken within the Trauma and Orthopaedics (T&O) training programme in Derriford hospital. The concerns were raised through the Quality Panel process in 2016, ARCP panel in 2017 and individual trainee issues raised with the Training Programme Director (TPD). The concerns were primarily focussed around insufficient access to training opportunities within elective surgery and arthroplasty surgery in particular which is potentially leading to adverse outcomes at the trainees ARCP.

The Panel recognised the engagement of the trainers within the T&O department in trying to resolve these issues. There was a clear desire expressed by the trainers to ensure good quality training was delivered within the department and a frustration of not being able to access the best training opportunities in alternative institutions.

There was a common theme of service commitments impacting on the training opportunity exposure (primarily access to arthroplasty surgery). It was noted that at the time of the visit, Stannon ward which takes post-operative elective cases was closed to Orthopaedic admissions and was being utilised as a ward for medical patients. The department appeared to be experiencing difficulties recruiting SHO’s which was creating rota gaps.  This has meant that registrars were ‘acting-down’ to cover the SHO on-call at night rota. The registrars felt uncomfortable managing medical problems with their surgical patients which lead to the potential for them to be requested to undertake tasks outside of their current competence.  Recent high profile cases had reinforced this view although they recognised and understood their duty to offer patients the best of care.

A relationship with the independent sector should be explored further to establish potential opportunities for trainees to perform elective surgical cases with an accredited supervision.

A work schedule (timetable) for each T&O registrar is required as a matter of urgency.
The requirements and recommendations are contained in the body of this report. The Trust is required to produce an action plan to provide solutions to these concerns. The implementation of the action plan and the evidence for it addressing the concerns will be monitored by HEE through our quality monitoring processes.

The Arthroplasty group need to develop training practices to identify cases for trainee surgeons such that an arthroplasty firm would give access to a minimum of 20 and aspiring to achieve 40 or more joint replacements with the right surgeons.  Trainees should be placed with those surgeons that offer the best of training.  The Torbay experience of improving arthroplasty numbers was discussed.


Outcome report completed by (name) Sophie Rose / Dr Martin Davis
Chair's signature Dr Martin Davis
Date signed 19th March 2018
HEE authorised signature Dr Martin Davis
Date signed 10/04/2018
Date submitted to organisation 10/04/2018



Job title Name
Director of Medical Education Dr Matthew Bowles



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?  YES
To whom was this fed back at the organisation, and who has undertaken to action? 
Fed back to the T&O trainers, management team and Trust representatives who were aware of risks and had already put an appropriate short-term plan in place.
Brief summary of concern

A potential patient safety issue was raised by trainees as they did not feel competent to ‘act-down’ to cover the SHO on-call at night rota. This relates to their ability to manage medical as opposed to surgical complications in post-op patients.

The Trust was already aware of this concern and had since recruited a number of doctors to cover the ‘SHO’ rota. The Trust had also imposed a ‘Safe minimum staffing level’ policy.

HEE would like submitted a copy of the ‘Standard Operating Procedure Policy’ which should protect trainees in such emergency circumstances 1st April 2018.



Related Domain(s) & Standards HEE and GMC 1&3
Summary of findings It was reported that trainees were having difficulties accessing elective operating lists particularly within arthroplasty surgery.
Required action
  • Trust to ensure access to the arthroplasty surgery in a sustainable fashion. This may involve securing a robust contractual agreement with other providers
  • The lack of a sustainable plan will potentially lead to placement of posts elsewhere in the training programme.


Related Domain(s) & Standards

HEE and GMC 1&3
Summary of findings It was reported that trainees were currently having difficulties accessing elective arthroplasty lists.
Required action
  •  Trust to submit work schedules for individual trainees affected in advance of a sustainable plan being formulated. This is urgent for the ST3 trainee who is due to rotate into this placement in February 2018 and the ST8 trainee who requires additional cases to successful gain CCT in October 2018. Submission required by 1st April 2018


Related Domain(s) & Standards

HEE and GMC 1&3
Summary of findings Concerns were raised that quality indicators such as protected research/admin time were being cancelled and not rescheduled.
Required action
  • Management and trainees to ensure that the rota team are aware of which sessions fall into this category and where cancelled they are either rescheduled or the trainee generates an exception report.


Related Domain(s) & Standards

HEE and GMC 1&3
Summary of findings It was reported that on occasions trainees had used annual leave to support mandatory exams and courses where study leave should have been granted.
Required action
  • Management to explore this further and if found to be accurate, annual leave should be reinstated to the trainees. Report required by 1st April 2018



Related Domain(s) & Standard(s)

HEE and GMC 1&3

Summary of findings
  • HEE recommended that management/rota coordinators maintain trainee input when making decisions and to maintain close working relationships.



Summary of discussions with groups



The panel met with 4 trainees from the Trauma and Orthopaedic programme based in Derriford.

Trainees stated that between September 2017 and November 2017 there were rota gaps within the SHO numbers (5 SHO’s supporting a 12 post rota) which resulted in a detrimental impact on their training opportunities. The trainees advised that they had worked with the service managers to develop a plan to enable priority setting for those training opportunities available.

The insufficient SHO numbers also raised potential patient safety concerns as the registrars were regularly being asked to ‘act down’ to cover the SHO on-call rota. The trainees did not feel competent to deal with the medical as opposed to the surgical problems that they encountered on these shifts. Trainees confirmed that there has since been an improvement with fewer vacancies and therefore less requests for them to act down.

It was discussed that trainees within the department were experiencing difficulties achieving the necessary opportunities to achieve competence with arthroplasty surgery. It was noted that at the time of the visit the elective orthopaedic ward had been closed due to NHS England’s winter pressure guidance. The panel and trainees discussed potential training opportunities and the current arrangements for trainees to attend operating sessions at independent facilities such as Tavistock Hospital and ISTC operated by Care UK.

It was raised that research and admin sessions were frequently cancelled and was more of a problem for the more junior registrars. Trainees also advised that in some cases annual leave had to be used to attend examinations/mandatory courses as study leave hadn’t been granted.

The main concern amongst the trainees was the lack of exposure to arthroplasty surgery within Derriford Hospital and the impact this is having on them achieving and completing the mandatory curriculum competencies.

It was confirmed that trainees are receiving excellent Trauma exposure and training at Derriford Hospital and there are plenty of opportunities to be involved in complex cases. The trainees confirmed that the trainers are engaged and keen to train.



5 trainers attended the session along with the clinical director who is also a trainer.

It was clear to the panel that the trainers are enthusiastic to train and are keen to make improvements to enhance the trainee’s experience.

The trainers agreed that the department was under staffed between September and November 2017 due to the low SHO numbers and as a consequence the trainees and consultants were being asked to act-down to cover the registrar rota. It was confirmed that a short-term solution had been implemented by recruiting additional numbers of SHO’s on a fixed term basis. It is critical that this becomes a sustainable solution to prevent recurrence of the recent issues.

It was confirmed that some trainers work at ISTC and Tavistock Hospital where a number of elective cases are undertaken that would be suitable procedures for trainees to undertake with supervision. They were happy to have trainees present and assisting in these centres but acknowledged that clarity from the various organisations would be required to enable this to take place. It was recognised that should trainees be unable to obtain adequate access to the required range of elective surgery then HEE would need to look at placing trainees elsewhere within the region for their curricula needs. HEE were advised that there are on-going negotiations with Care UK to gain approval for training at ISTC. HEE agreed to support this arrangement under the provision that the trainees were trained by a GMC accredited trainer and the site had GMC approval as a training site.



The management team agreed with the concerns raised by the trainees and trainers relating to the registrars covering the SHO on-call at night bleep and have already worked alongside the trainees to impose a safe minimum staffing level to support the trainees in such circumstances.

It was clear that the department had been under staffed recently and the management team had to balance service provision, patient safety and training which did have an impact on training opportunities. The panel were advised that the department also had difficulties with locum staff who could be recruited to cover theatre sessions but not ward cover and this was exacerbating the training issues. The Trust has since recruited a number of SHO’s on a fixed term basis who will work on the ward which offers a short-term resolution. HEE would like to see a sustainable long-term action plan to ensure that this risk is minimised as much as possible.

Management were not aware of the concerns raised regarding the protected research/admin time being cancelled. HEE were advised that trainees are now involved in the rota coordination therefore were unsure why this concern had not been raised previously. Management agreed to look into building a closer working relationship with the trainees to help resolve any future service demands.  It was agreed for a member of the management team to attend an ARCP to gain a further understanding of the trainees training requirements.

The management team advised that the elective ward was currently closed however hope for this to be re-opened by the beginning of March.  It was agreed that there is a requirement to investigate all options for trainee exposure to elective surgery including opportunities for trainees to work sessions in the independent sector

HEE advised that the department there is the opportunity to engage with the HEE workforce and transformation team to look at any alternative workforce models to provide sustainable cover of wards for the future.



  • The visiting team acknowledged the Trust’s engagement with the process and acknowledgement that issues exist.
  • There were concerns with the lack of elective lists within Arthroplasty for the trainees to be able to achieve the necessary curriculum competences. The Trust will need to provide HEE with tailored individual training plans for all trainees at risk within Arthroplasty which requires immediate development with a system in place to monitor progress against the plan by 1st April 2018. 
  • There is not currently a plan in place to support the Arthroplasty exposure long-term. The Trust need to look at alternative hospitals within the locality where trainees can achieve the necessary competencies. HEE would require a long term action plan from the trust to maintain training at Derriford Hospital within this specialty.
  • There is no sustainable action plan in the medium to long term to solve the problems with SHO rota cover. HEE to be sent the ‘Safe Minimum Staffing’ document and the ‘Standard Operating Procedure Policy’.
  • The process for filling SHO rota gaps could be improved by looking at alternative workforce models. This needs to be followed through by contacting the workforce and transformation team at HEE.
  • Management to maintain trainee input on decision making and to look at building a closer working relationship.
  • Trust to ensure that Quality indicators such as protected research/admin time are honoured and if cancelled it is either exception reported or rescheduled at the earliest opportunity.
  • Inadequate training opportunities and failure to improve arthroplasty numbers could result in the loss of training numbers of a lack of recognition or arthroplasty training in the trust.



Date of report: 26th January 2018

Author: Sophie Rose/Dr Martin Davis

Job Title: Quality Support Administrator / Head of Quality