Executive summary
The panel would like to thank the senior leadership team at EKHUFT for accommodating this risk-based review. The visit and subsequent discussions focused on the Trust’s response to the red outliers in the General Medical Council’s (GMC) National Training Survey (NTS) results in 2024. The visiting panel were keen to understand the relationship between the education and operational teams and how different areas of management work together to support the trainee experience.
The panel heard from senior representatives of the education and operational teams that there are regular quality assurance and governance meetings to deal with outstanding issues in the AMU wards, and that feedback from resident doctors is gathered regularly and helps to support decision making. The Trust presented actions they have taken to address concerns previously identified through the GMC NTS 2024 survey details of which have been included within the relevant domains of this report.
The panel met with Clinical and Educational Supervisors in the Acute Medicine and Emergency Medicine departments and six resident doctors with experience working on the AMU. Unfortunately, there were no foundation doctors available to meet with the panel on the day and therefore, a follow up visit was scheduled for 21 May 2025 led by the Associate Dean and Director of KSS Foundation School who met with Foundation residents.
The review identified a generally supportive and friendly culture at QEQM, with good access to teaching and a proactive operational team. However, concerns were raised regarding consultant staffing and supervision particularly in the Plus24, St Augustine, and AMU A & B wards.
The trainee focus group with Foundation doctors held on 21st May 2025 supported the review’s findings of the positive culture at the site, but identified issues around handover, induction in the Acute Medical Unit (AMU) and cardiology reviews. Therefore, twelve mandatory requirements have been issued to the Trust and will be monitored via an action plan.
Review overview
Background to the review
NHS England Kent, Surrey & Sussex (KSS) Education Quality arranged this risk-based review in response to concerns raised through the Foundation School regarding the clinical learning environment within Acute Internal Medicine, Anaesthetics, and Surgery following a deterioration in the General Medical Council National Training Survey (GMC NTS) 2024 results.
The review focused on medical training specifically in the Acute Medical Unit (AMU) at Queen Elizabeth, The Queen Mother Hospital (QEQM), part of East Kent Hospitals University NHS Foundation Trust (EKHUFT).
Who we met with
Learners
- One Internal Medicine Trainees (IMTs), two Higher Specialty Trainees (HSTs) and six Locally Employed Doctors (LEDs) who are part of the medical on-call.
- Foundation Doctors were met with separately on 21st May 2025 (further details in Executive Summary and body of the report).
Educators
- Clinical & Educational Supervisors in Medicine
Trust representation
- Chief Operating Officer
- Chief Medical Officer
- Trust Operations Managers
- Director of Medical Education
- Medical Education Managers
- Foundation Training Programme Director
- Medical Director of Wiliam Harvey Hospital Care Group
- Medical Director of QEQM Care Group
- Clinical Leads
- Faculty Leads
- College Tutors
- Guardian of Safe Working
Review panel
Education Quality Review Lead
- Alison Crocker, Associate Dean
Specialty Expert
- Paul Reynolds, Director of KSS Foundation School
- Shariq Lanker, GP Associate Dean for East Kent
- Burhan Khan, TPD for Medicine
External Specialty Expert
- Nicholas Dalmon, Doctor in Training Representative
NHSE Education Quality Representative(s)
- Michael Hobkirk, Associate Dean, Observer
- Alex Bamford-Blake, Education Quality Project Officer, Scribe
Supporting roles
- Sallie Nicholas, Lay representative
Review findings
Quality Domain 1: Learning environment and culture
The Trust reported that the operations team are more accessible and visible on site than previously. The panel heard that there is improved communication between the operational and educational teams, with a WhatsApp group that allows both teams to share training and site pressures and collaborate on a same-day solution. The panel also heard that there are good working relationships between medical specialties as well as consultants in Acute Medicine and the Emergency Department.
However, the review panel were concerned that the Trust could not provide an accurate number or grade of doctors in the AMU during the review panel’s visit. This contributed to the situation where there were no foundation doctors to meet with the panel despite assurance given to the education department from the rota teams, they were unable to accommodate Foundation doctors attending on the day.
Facilities
The panel heard from residents that the medical on call team and the team on AMU do not have adequate area desk or seating when working and often use a computer-on-wheels. The Trust reported that a new wellbeing space for residents had just opened, which will provide space to work as well as act as a doctor’s mess. The panel considered that wellbeing space should be reserved for this purpose and there should be separate areas for staff to carry out work activities.
The panel heard from residents that, though clinics are ringfenced in their schedule, clinic room availability can be an issue unless they give consultants enough notice to organise one, and so residents are still having to share with the consultant. The panel considered that this arrangement does not fulfil the educational needs for mandatory clinic attendance to comply with training needs and this issue needs to be addressed with a standard operating procedure for clinic attendance and room availability. Please see Mandatory Requirement MR-AMU-04.
It was also reported that there are not being enough bleeps to cover all the wards on the morning shift leading to calls to the medical regs for assistance. The panel considered that this was a patient safety issue and therefore a mandatory requirement has been put in place for a standard operating procedure to ensure that there are sufficient bleeps and cover for all areas that the AMU team cover, both inpatient and on take. Please see Mandatory Requirement MR-AMU-05.
Consultant staffing
The panel heard residents feel there is inadequate consultant presence on some wards. The Plus 24 area, which consists of longer stay patients, has no dedicated consultant on a daily basis or over the weekend. Resident doctors reported they felt the care these patients receive is less than what is received by patients admitted to wards. The Trust reported that recruitment for consultant in acute medicine is underway. The panel considered that lack of named consultant cover for this area is a patient safety issue and therefore a mandatory requirement has been put in place for named consultant cover to be provided for the Plus 24 area in and out of hours. Please see Mandatory Requirement MR-AMU-06.
In the St Augustine ward, a 30-bed ward for patients waiting for care/nursing home placements who have been deemed medically fit for discharge, there is only one resident doctor on weekdays and no dedicated cover over the weekend. It was reported that these patients are not routinely reviewed by consultants and can be on this ward for several weeks without consultant review. The panel considered that this was a patient safety issue and therefore a mandatory requirement has been put in place for named consultant cover to be provided for St Augustine ward in and out of hours. Please see Mandatory Requirement MR-AMU-07.
It was reported that during the nights on AMU A & B there are two registrars, often both clerking, and three SHOs, one for ward cover and two for clerking, looking after up to 53 patients as well as the Plus 24 patients, and acute admissions. The team covering AMU A & B over the weekend consists of one SHO each during the day which residents reported as impossible with that number of patients, some of whom are acutely unwell. Residents reported they would benefit from a registrar. The panel considered that registrar cover of AMU A and B over the weekends needs to be made explicit and a mandatory requirement has been issued for this. Please see Mandatory Requirement MR-AMU-08.
The panel heard that during the week cardiology consultants are reachable either on-site or by phone and there is good cath lab access. However, the weekend cover can be variable, with the cardiologist either based on-site or at William Harvey Hospital (WHH). This can lead to patients needing to be transferred as an emergency to WHH or up to a 24-hour delay in accessing a cardiology review.
When asked about the culture of the site, residents reported QEQM as a friendly, supportive hospital.
Quality Domain 2: Educational governance and commitment to quality
The Trust reported that there are regular teaching sessions, both virtual and face-to-face, and that they are well attended and bleep-free. The panel heard from residents that teaching opportunities are substantial and that they are usually able to attend the teaching sessions they want to despite OPEL 4 level service pressures. However, the panel heard that discharge coordinators on the AMU can be very insistent (described as “pushy”) regarding requesting doctors to complete patient discharges and this activity can be an impediment to doctors on the AMU attending their teaching. The panel considered that AMU management should be reminded regularly of the need for residents to attend their bleep-free teaching and the Guardian of Safe Working Hours should ensure this is monitored and reinforced, and a mandatory requirement has been issued for this. Please see Mandatory Requirement MR-AMU-09.
Quality Domain 3: Developing and supporting learners
Supervision
The panel heard that, due to lack of substantive consultants, there is a reliance on locum doctors in Acute Medicine to provide supervision, some of whom are not trained as ES, and this has led to gaps in educational supervision (please see Mandatory Requirement MR-AMU-10). The Trust reported that trainees have fed back that they are meeting with their Clinical Supervisors (CS) and have good access to their Educational Supervisors (ES) However, the panel heard from residents that since one ES has been on long-term sick leave, this ES’s trainees have not had a named educational supervisor designated as a replacement, although resident doctors reported being able to access the original ES via email during their sick leave. In line with GMC requirements, the panel considered that all ES and CSs must be GMC-accredited trainers and where there is supervisor sickness, there must be a plan for sickness cover of the supervisor role. Mandatory requirements have been issued for these items. Please see Mandatory Requirement MR-AMU-11.
Registrar Cover
The panel heard that there has been a reduction from two registrars to one over weekends, raising concerns about supervision and workload.
The panel heard that some residents feel they are doing tasks that would be suitable for more junior colleagues, with one senior resident reporting they did not have opportunity to develop leadership and management skills required for career progression.
Handover
The panel heard from residents that there is an inconsistent handover process. Residents reported night handovers are focussed on unwell patients and that they often check with the head nurse to explain Careflow or Sunrise additional comments.
The Trust reported that recently opened facilities with designated handover areas and the reintroduction of Friday evening handover should positively impact training and education opportunities.
Quality Domain 4: Developing and supporting supervisors
Job planning and workload impact
Supervisors reported that they have 0.25 SPA time ringfenced in their job plan, but that their time and focus can be stretched due to the clinical demands of two sites and named ES and CS time is not ringfenced separately. The high patient volume can affect their ability to supervise and teach effectively.
Additionally, due to the lack of substantive consultants in acute medicine, when there is sickness or annual leave, the remaining consultants are extremely stretched reviewing new admissions, AMU patients, and SDEC, which impacts the support and teaching opportunities available for the residents. When asked about the lack of substantive consultants in acute medicine, it was reported that recruitment is underway, but that three adverts over the last six months has not yielded applicants with sufficient experience.
Quality Domain 5: Delivering programmes and curricula
This requirement was not specifically discussed as part of the review, however themes in other sections such as outpatient clinic requirements link to this domain.
Quality Domain 6: Developing a sustainable workforce
This requirement was not specifically discussed as part of the review, however themes in other sections may link to this domain.
Addendum following visit on 21 May 2025
Since the Foundation doctors were unavailable on the 20th March 2025 at the risk-based review, the Associate Dean and Head of the Foundation School returned on 21st May 2025 to meet with them.
Staffing
The panel heard positive reports of improvements made on both AMUs. Staffing levels have improved, and the workload is busy but manageable. Management of the rota was reported as working well, with those responsible being approachable, helpful and flexible to doctors’ needs. The introduction of monthly off-site teaching days for the Foundation doctors was reported as being useful and easy to access. The panel also heard that one particular registrar was extremely keen to teach and facilitate opportunities for Foundation doctor learning, and when present they were described as ‘the glue that holds the department together’.
Handover
The panel heard that handover at the weekends for patients already admitted to the ward is poor. The incoming medical staff meet all together where any sick inpatients are handed over but there is no formal handover for stable ward patients with the result that doctors have responsibility for patients they do not know. The panel heard that Foundation doctors generally ask the senior nurses about the ward patients when they arrive and ask for a verbal handover from them, but they developed this approach themselves out of necessity in the absence of any other handover of these patients. Please see Mandatory Requirement MR-AMU-03.
Induction
The panel heard that there is an induction handbook for the department, but this is difficult to find and is not updated. There was no induction for the on-call shifts resulting in Foundation doctors (some in the first placement of their first Foundation year) arriving for on-call on the first weekend of the job without knowing where to go or what their duties were. There are isolated instances of shadowing opportunities, but these are organised by outgoing Foundation colleagues on an ad-hoc basis, and the incoming trainee did this on their off day. This opportunity was described as having been very helpful. Please see Mandatory Requirement MR-AMU-01.
Specialty review
The panel heard that access to specialty reviews was very different for different specialties. Gastroenterology was praised for being very responsive and helpful. Cardiology cover in East Kent Hospitals is provided cross site so there are often times when there is no cardiology registrar or consultant on site at QEQM, and in this situation verbal advice is given over the phone. However, it can be difficult to get a cardiology review of ward patients (i.e. those on AMU who have cardiology issues but are not on Critical Care Unit) even when there are cardiologists on site. The panel heard of multiple instances where ward patients have waited for longer than 48 hours for a review (one waiting for two weeks) which represents a significant patient safety issue. The panel heard of multiple instances where Foundation doctors have made cardiology referrals to tertiary units themselves and even instances where they have presented cardiology patients in the virtual regional tertiary cardiology multi-disciplinary team because of reluctance of more senior doctors on the AMU to do this instead. Please see Mandatory Requirement MR-AMU-02.
The panel heard that exception reporting was encouraged but that Foundation doctors often received feedback suggesting that they should manage their time better as a solution to having to stay late. They were aware of the Guardian of Safe Working Hours and the Freedom To Speak Up guardian and reported that there are a lot of opportunities for trainees to give feedback.
Culture
The panel heard that the medical staff and the hospital in general are very friendly, and when concerns were raised as a group about a locum consultant’s bullying behaviour, the hospital responded quickly and efficiently which they appreciated. The Foundation doctors were aware that there are competing demands at the weekend, with the nurses feeling pressure to discharge patients while the doctors are under pressure to ensure that patients not fit for discharge are investigated and treated in a timely manner. The panel heard that this pressure to discharge patients may be partly the reason for multiple instances reported of confrontational nursing behaviour. There were also reports of nurses pressurising doctors to change prescriptions in which the nurse had given intravenous fluids that were different from the fluids prescribed, and the doctors being made to feel that it was their fault for prescribing the ‘wrong’ fluid in the first place – and that senior nursing staff had backed up the more junior nurse in this assertion. We recommend that the Trust organise some facilitated discussion between doctors and nurses on AMU to further mutual understanding of competing pressures at the weekend, in order to improve patient safety and flow, and a mandatory requirement has been issued to address this issue. Please see Mandatory Requirement MR-AMU-12.
Requirements
Immediate mandatory requirements
No IMRs were issued.
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| The doctors reported a lack of robust departmental induction to the acute medical unit. | We require evidence of a robust departmental induction to AMU A and AMU B which should include clear explanations of roles and responsibilities of each doctor both in and out of hours, and an up-to-date departmental induction handbook which should be provided to each trainee. Evidence required: a timetable of departmental induction; an updated handbook; a log of shadowing undertaken; and trainee feedback after the August intake. Please submit by Friday 3 October 2025. | MR-AMU-01 |
| Foundation doctors reported having to make referrals to tertiary units for cardiology input without senior support. This was in part due to delays in review by the senior clinicians in the cardiology team. | We require evidence of clearly documented and communicated escalation routes for patients requiring cardiology review on AMU A and AMU B to enable patients to be seen in a timely manner. We require confirmation that Foundation doctors have no clinical responsibility in the process of requesting tertiary unit referrals. Evidence required: guidance document, signed off by cardiology clinical leads, stating clear escalation routes sent to all senior medical and nursing staff for dissemination, which should also be incorporated into the departmental handbook. Please submit by Friday 3 October 2025. | MR-AMU-02 |
| The panel heard that doctors had to spend time searching around wards to discuss plans with the nurses as there was no handover in place, especially at weekends. | The Trust must ensure that there is a scheduled and structured handover in place between medical and nursing staff including at weekend. Evidence required: handover document and evidence of handover taking place (audit and attendance record) with feedback at next quarter after implementation. Please submit by Friday 3 October 2025. | MR-AMU-03 |
| The panel heard that doctors were having to organise their own room availability in outpatients and sometimes had to share with the consultant. | The Trust must provide a standard operating procedure to ensure that trainees allocated to clinics have separate rooms to allow them to see patients independently and confirm that trainees do not have to organise this for themselves. Please submit by Friday 3 October 2025 | MR-AMU-04 |
| The panel heard that there are not enough bleeps to cover all the wards on the morning shift leading to calls to the medical regs for assistance. | The Trust must provide a standard operating procedure and evidence of implementation to ensure that there are sufficient bleeps and cover for all areas that the AMU team cover, both inpatient and on take. Please submit by Friday 3 October 2025 | MR-AMU-05 |
| The panel heard residents feel there is inadequate consultant presence on some wards. The Plus 24 area, which consists of longer stay patients, has no dedicated consultant on a daily basis or over the weekend. Resident doctors reported they felt the care these patients receive is less than what is received by patients admitted to wards. | The Trust must provide evidence of named consultant cover for the Plus 24 area in and out of hours. Please submit by Friday 3 October 2025 | MR-AMU-06 |
| The panel heard that in St Augustine ward, there is only one resident doctor on weekdays and no dedicated cover over the weekend. It was reported that these patients are not routinely reviewed by consultants and can be on this ward for several weeks without consultant review. | The Trust must provide evidence of named consultant cover for St Augustine ward in and out of hours. Please submit by Friday 3 October 2025 | MR-AMU-07 |
| The panel heard that resident doctor cover of AMU A and B over the weekend was limited to one SHO and no registrar which the residents felt represented an impossible workload | The Trust must provide evidence that registrar cover of AMU A and B over the weekend is made explicit to resident doctors both at induction and on weekend shifts. Please submit by Friday 3 October 2025 | MR-AMU-08 |
| The panel heard that discharge coordinators on the AMU can be very insistent regarding requesting doctors to complete patient discharges and this activity can be an impediment to doctors on the AMU attending their teaching. | The Trust must provide evidence that AMU management are reminded regularly of the need for residents to attend their bleep-free teaching and the Guardian of Safe Working Hours should ensure this is monitored and reinforced. Please submit by Friday 3 October 2025 | MR-AMU-09 |
| The panel heard that there has been reliance on locum doctors in acute medicine to provide supervision, some of who are not GMC-accredited trainers | The Trust must provide evidence that all named ES and CSs are GMC-registered trainers. Please submit by Friday 3 October 2025 | MR-AMU-10 |
| The panel heard that one ES had been on long term sick and no clear plan was made for covering this role | The Trust must provide evidence of the procedure for covering educational or named clinical supervisor sickness absence. Please submit by Friday 3 October 2025 | MR-AMU-11 |
| The panel heard evidence of cultural issues within the AMU environment due to workload pressures | The Trust must provide evidence of having provided opportunities for facilitated discussion between doctors and nurses on AMU to further mutual understanding of competing pressures at the weekends. Please submit by Friday 3 October 2025 | MR-AMU-12 |
Report approval
Report completed by: Alex Bamford-Blake, Education Quality Project Officer
Review lead: Alison Crocker, Associate Dean for Kent, Surrey & Sussex
Date approved by review lead: 3 July 2025
NHS England authorised signature: Jo Szram, SE Regional Postgraduate Dean
Date authorised: 4 July 2025
Final report submitted to organisation: 18 July 2025