Executive summary

The review panel was thankful to the Placement Provider (PP) for accommodating this review and for facilitating good attendance. PP representatives presented a summary of the current issues and actions that have been taken to address the issues along with plans for future improvements. The review panel noted that the department was working hard to address issues and acknowledged the significant workload pressures faced by all Emergency Medicine Departments (ED).

PP representatives were aware that lack of consultant visibility and issues with clinical supervision was a recurring issue for Resident Doctors (RDs). The review panel noted that direct access to supervision needed to be improved with supervisors being more visible for all RDs. The review panel strongly advised that the PP should aim to increase the number of consultant posts in line with the Royal College of Emergency Medicine recommendations and provide consultant cover in person from 8am to midnight, 7 days a week.

Given that clinical supervision for RDs in postgraduate training was often provided by Locally Employed Doctors (LEDs), the review panel noted that specific training in clinical supervision was required to support these LEDs, particularly International Medical Graduates (IMGs) who may be less familiar with the curriculum and teaching culture. 

The review panel noted concerns about the disconnect between the feedback the department had received from the RDs and the feedback that RDs provided anonymously, for example via the General Medical Council (GMC) National Training Survey (NTS). PP representatives acknowledged that more work was needed to explore why RDs do not feel comfortable to raise concerns to the department directly. PP representatives also noted that the issues being raised were not new and they needed to improve feedback loops to demonstrate the work that was being done to resolve recurring issues.

NHS England’s Intensive Support Framework (ISF) rating of Emergency Medicine at Whipps Cross Hospital remains at ISF 2. This report includes specific requirements for the PP to take forward, which will be reviewed by NHS England – London as part of the three-monthly action planning timeline.

Review Overview

Background to the review

This Senior Leader Engagement Visit (SLEV) was initiated in response to negatively outlying 2024 General Medical Council (GMC) National Training Survey (NTS) post specialty level results for Foundation Year Two (FY2) and specialty level training in emergency medicine at Whipps Cross Hospital.  

The Placement Provider’s (PP’s) self-report on these results in September 2024 highlighted that they were unexpected, as they differed from learner feedback obtained through recent Local Faculty Group meetings and a focus group session with the Director of Medical Education. The department’s consultant body had also reportedly worked hard in recent years to improve resident doctors’ training experience in emergency medicine.  

The self-report set out some improvements the department intended to make to address the NTS results, including:  

• Increasing the number of consultants in the department 
• Recruiting more clinical educators 
• Improving handovers 
• Introducing wellbeing sessions for the emergency medicine team 
• Improving training and supervision for locally employed doctors 
• They also planned to conduct a focus group meeting with learners that had trained in emergency medicine in the last two to three years, to obtain further feedback to help guide improvements. 

The department planned to measure the efficacy of these improvements via learner feedback at Local Faculty Group meetings, an anonymous learner survey halfway through training placements and through next year’s NTS.  

This SLEV in February 2025 was intended to be a supportive discussion around these improvement plans and their sustainability. 

The following evidence provided by the Trust was used by the review panel to formulate the key lines of enquiry for the review. The content of the review report and its conclusions are based

solely on feedback received from review attendees:

• Emergency Department Feedback and Action Plan
• Breakdown of educational and clinical supervisors within the department
• Breakdown of learner groups within the department
• Exception Report Data January 2025
• Quality Improvement Projects 2024-2025
• Teaching and simulation programmes and attendance lists
• Departmental Induction Feedback – April 2024 and December 2024
• Local Faculty Group (LFG) minutes- March 2024, August 2024 and November 2024
• Medical Education Committee (MEC) Meeting Notes- July 2024
• Complaints spreadsheet for last 3 years
• Datix Report – Emergency Medicine
• Current Rotas and fill rate 2024-2025
• Work schedules for the different learner groups in scope

Who we met with

• Director of Medical Education
• Deputy Director of Medical Education
• Emergency Department Consultant & Deputy Director of Medical Education
• Medical Education Manager
• Guardian of Safe Working Hours
• Clinical Director
• Medical Director
• Educational Lead
• Divisional Director for Emergency Department and Medicine
• Trust Dean
• Associate Director of Medical Education
• Lead for Postgraduate Medical and Dental Education
• Associate Director of Nursing

Review panel

• NHS England – London Review Lead, Louise Schofield, System Dean, North East London
• Specialty Expert, Jamal Mortazavi, Head of the London Specialty School of Emergency Medicine NHS England – London
• Specialty Expert, Alice Carter, Associate Dean for Foundation Training (Pan-London) NHS England – London
• Specialty Expert, Olu Adenugba, Emergency Medicine Training Programme Director and Emergency Medicine Consultant Lewisham and Greenwich NHS Trust
• NHS England – London Education Quality Representative, Rebecca Bennett, Education Quality Coordinator    

Review findings

Workload

Placement Provider (PP) representatives informed the review panel that the department had recently increased the number of Resident Doctor (RD) posts and had increased the number of senior RDs at night. It was noted that not all of the additional posts had been recruited to yet.

The review panel was informed that a lot of patients were being assessed in corridors in the Emergency Assessment (EA) area when being handed over from the ambulance, PP representatives identified this area as a level of high risk.

Consultant staffing levels and clinical supervision

The review panel asked how the department ensured supervision was available even at the busiest times of the day. PP representatives reported that there were 2 consultants in majors until 10pm. The review panel was informed that after 10pm there was a single consultant on-call from home overnight. PP representatives also informed the review panel of a recent pilot that the department had been running to have a consultant based in the EA area which had improved decision making and patient flow through the department. PP representatives noted that there were medical consultants available in Emergency Medicine Department (ED) supporting medical patients and advised RDs could approach them as an additional senior decision maker if they needed to.

PP representatives acknowledged that lack of consultant visibility and issues with clinical supervision was a recurring issue for RDs. PP representatives reported that they had recently recruited more consultants to help with issues around supervision and the paediatric ED rota had been amended to ensure there was cover 24 hours a day, 7 days a week. It was noted that the department was hoping to bring the consultant staffing level up to 15 Whole Time Equivalent (WTE) including 2 paediatric ED Consultants. PP representatives advised that 15 WTE would allow a permanent consultant in the EA area.

PP representatives advised that there had been more emphasis on the importance of consultants being physically present in the clinical environment. It was reported that due to staggered shift patterns the consultant starting at 8am was the only consultant available until 11am and had to cover the whole department therefore RDs might feel that there was no visible consultant supervision. PP representatives advised that the ED had a large footprint which contributed to the lack of visibility of consultants. The review panel enquired about how the department was addressing this. PP representatives advised that there was a morning huddle with nursing staff and contact details were shared at that meeting. It was also noted that a sign-in process had been implemented where RDs meet the consultant in charge, so they know where to go for help. It was noted that consultants would be with the nurse in-charge in majors when they were not seeing patients. PP representatives stressed that consultants were always available to be contacted via the bleep or tannoy system however the review panel felt this might be more challenging for less experienced members of the team such as foundation RDs.  

The review panel stressed the importance of ensuring there was a sufficient number of consultant posts in the department to ensure appropriate and visible clinical supervision. The review panel also noted that it was imperative that sufficient time was allocated in consultant job plans for administrative work.

The review panel enquired about the training that was provided to Locally Employed Doctors (LEDs) who had supervision responsibilities for RDs. PP representatives advised that this was part of their induction but acknowledged that it did take some time for the LEDs to become familiar with the teaching culture and curriculum. PP representatives advised that many of the LEDs were International Medical Graduates (IMGs) and followed a very well-established IMG induction process. It was noted that all LEDs were allocated a clinical supervisor who reviewed a checklist with the LEDs to assess their skills and establish their training needs. PP representatives reported that LEDs were given specific training for being a senior in the department, for example running night shifts, and it was noted that the LEDs were allocated education and development time for them to address their training needs. It was also confirmed that new LEDs did not do night shifts on their own and were paired with someone with more experience whilst they were new. The review panel noted that it was important to invest the time in training IMGs to be approachable and available for more junior RDs to come to them for help. PP representatives acknowledged that these skills took more work and time to achieve. PP representatives clarified that there was always a senior RD (LED or Specialty RD) scheduled at night who they had a high level of confidence in their supervision skills.

PP representatives also reported that the department had increased the number of Trust Clinical Educators to support training and education in the department.

Raising concerns and feedback

PP representatives acknowledged that whilst there was some improvement in the 2023 General Medical Council (GMC) National Training Survey (NTS) results, there was significant deterioration in the 2024 results. The review panel was informed that the department had developed a feedback tracker and had sought feedback from RDs. It was advised that the tracker had helped identify 22 areas for improvement including consultant supervision and presence, ability to complete assessments and RDs completing work which was not relevant to their role or training. PP representatives reported that some of these issues were more systemic issues across the hospital and beyond the remit of the department.

The review panel noted that there were regular Local Faculty Group (LFG) meetings and PP representatives advised that they were actively engaging with RDs to gather feedback. The review panel commented about the significant difference in the feedback received by the department and the feedback that RDs provided anonymously, for example via the GMC NTS. PP representatives believed that it might be easier for RDs to give honest feedback anonymously. PP representatives also noted that a high workload and operational pressures may have impacted the GMC NTS feedback, the review panel noted that workload was an issue for other PPs in the GMC NTS survey but there was generally better feedback across the other indicators, which was not the case for the Whipps Cross Hospital results.

It was reported that the Director of Medical Education (DME) had also conducted focus groups with RDs which had yielded more candid feedback from RDs than departmental mechanisms. PP representatives reported that RDs may feel more comfortable raising issues outside of the department as there was less perceived risk of any repercussions on their career. PP representatives clarified that the RDs may feel this way whether that risk was founded or not. PP representatives informed the review panel that RDs could also provide feedback to the Trust Psychologist.

PP representatives acknowledged that more work was needed to explore why RDs do not feel comfortable to raise concerns to the department directly. PP representatives also noted that the issues being raised were not new and they needed to improve feedback loops to demonstrate the work that was being done to resolve recurring issues.

Teaching

The review panel was informed that there was simulation training once a week in the department. It was also noted that there was an ultrasound clinic every Wednesday where RDs could do supervised scanning. PP representatives advised that in response to feedback about access to assessments the department initiated a Case Based Discussion (CBD) clinic where RDs could book appointments to complete assessments.

PP representatives acknowledged that Emergency Medicine was a challenging specialty to work in and therefore had incorporated wellbeing and psychological support into the teaching schedule.

PP representatives informed the review panel that they had improved their advertising of education opportunities in response to recent feedback from RDs that there were not aware of the education opportunities in the department.

Areas that are working well

Areas for improvement

Immediate mandatory requirements

Mandatory requirements

Recommendations

Report approval

Report completed by: Rebecca Bennett, Education Quality Coordinator, NHS England – London
Review lead: Louise Schofield, System Dean North East London, NHS England- London
Date approved by review lead: 12 March 2025

NHS England authorised signature: Vivienne Curtis, System Dean, NHS England – London
Date authorised: 8 April 2025

Final report submitted to organisation: 9 April 2025