Executive summary

The review panel was grateful to the placement provider (PP) for accommodating this review and facilitating good attendance. PP representatives presented a summary of the current issues and actions that have been taken along with plans for future improvements. The review panel noted that the PP Executive team were engaged with the educational improvement process and were working hard to address challenging consultant behaviour within acute internal medicine (AIM) at St Helier Hospital.

The review panel noted that the plan appeared to be robust; however, there were concerns around time frames for implementing these plans.

It was reported that avenues for raising concerns were improved within the department. PP representatives reported good attendance at resident doctor (RD) forums (RDF), which enabled RDs to raise concerns. The review panel was pleased to hear of instances where RD feedback resulted in changes to the department.

The PP reported that issues around rota design and educational supervision had been resolved using action plans. However, the review panel noted that feedback from the 2025 General Medical Council (GMC) National Training Survey (NTS) suggested these areas still required improvement. The review panel recommended that the PP examine recent feedback in these areas.

The review panel noted concerns about the ongoing issues around clinical decision making and behaviours of a minority of consultants within the department. The PP representatives acknowledged that this was a challenge. It was noted that this concern was also felt by RDs.

The PP representatives described initiating a collaboration, following NHSE signposting, with the team at West Middlesex University Hospital and the Hillingdon Hospitals NHS Foundation Trust who had successfully delivered educational improvement with similar challenges. The review panel strongly recommended that the PP continued to engage in this process.

NHS England’s Intensive Support Framework (ISF) rating of acute internal medicine at Epsom and St Helier University Hospital NHS Trust remains at ISF 2. However, the review panel advises that if significant progress is not observed as evident through RD feedback by 1 December 2025, the ISF rating will be raised, and further intervention will be considered. 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) has been initiated in response to limited progress in action plans following the 2024 General Medical Council (GMC) National Training Survey (NTS) results. The 2024 GMC NTS showed negatively outlying results for acute internal medicine (AIM) at St Helier Hospital which resulted in a self-report being issued. The PP was issued with an action following their self-report submission, the first response to this action was submitted in December 2024.

The content of the review report and its conclusions are based solely on feedback received from review attendees. The following evidence provided by the PP was used by the review panel to formulate the key lines of enquiry for the review:

• Acute Medical Unit (AMU) latest action plan 1
• AIM supervisor allocations and grades
• Exception reports
• AMU teaching attendance August 2024 – January 2025
• Foundation year 1 (FY1) simulation attendance April 2024 – April 2025
• FY1 teaching 2024 – 2025 Medicine attendance
• Internal medicine training (IMT) attendance master sheet – 1
• AIM induction feedback – August 2024
• Foundation joint Local Faculty Group (LFG) meeting – November 2024
• IMT LFG minutes – May and November 2024
• FY1 General medicine Epsom General Hospital (EGH) work schedules – November 2024 and April 2025
• Specialty training year 1-2 (ST1-2), core training year 1-2 (CT1-2) General medicine St Helier Hospital (STH) work schedule – November 2024
• ST1-2, CT1-2 General medicine EGH work schedule – November 2024
• Specialty training year 3-5 (ST3-5), core training year 3 (CT3) General medicine EGH work schedule – November 2024
• ST3-5, CT3 General medicine STH work schedule – November 2024

Who we met with

• Director of Medical Education
• Medical Education Manager
• Educational lead for Acute Internal Medicine
• Foundation Training Programme Directors
• Freedom to Speak Up Guardian
• Guardian of Safe Working Hours
• Chief Executive
• Clinical Director/Clinical Lead for Acute Internal Medicine
• Clinical Director for Inpatient Medicine
• Chief Medical Officer
• Associate Medical Director
• Group Chief Medical Officer
• Divisional/General Manager
• Service Manager
• Managing Director

Review panel

• System Dean- South West London, NHS England – London, Bhanu Williams, Education Quality Review Lead
• Deputy Head of London Specialty School of Medicine, NHS England – London, Jonathan Birns, Speciality School of Medicine Representative
• Deputy Foundation School Director, London Foundation, NHS England – London, Mark Cottee, Foundation School Representative
• Education Quality Assurance Programme Manager (London), William Henderson, General Medical Council Representative
• Education Quality Coordinator, NHS England – London, Lauren Thomson, Education Quality Representative
• Deputy Education Quality Manager, NHS England – London, Louise Brooker, Education Quality Representative
• Education Quality Coordinator, NHS England – London, Rebecca Bennett, Education Quality Representative (supporting role)

Review findings

Clinical decision making and patient safety

The review panel was very concerned about the ongoing issues with clinical decision making by a minority of consultants in acute internal medicine (AIM). The review panel described previous reports from resident doctors (RDs) who were concerned about the clinical advice they were given and about patient safety. Placement provider (PP) representatives confirmed that there was a lack of trust in the decision making of consultants.

PP representatives reported that some RDs were making decisions on the management plans of patients with little input from consultants. It was further noted that some RDs described significant concerns about the quality of plans from some consultants and were seeking advice from consultants outside of the department to check and adjust management plans where appropriate. 

PP representatives acknowledged challenges in resolving this issue and holding consultants to account. PP representatives explained that when looking at patients’ notes to capture this activity, RDs had been writing the notes in a manner that made the patients appear safe. It was reported that this did not allow the PP representatives sufficient evidence to challenge consultants as safe decision making was documented by RDs. It was noted that this concern was felt by RDs in the Acute Medical Unit (AMU).

PP representatives described plans to recruit new consultants and conduct peer reviews of clinical practice using consultants from St George’s University Hospitals NHS Foundation Trust to evaluate clinical decision making and consultant behaviour. The review panel expressed the view that peer observation may result in initial improvements due to observer effects and encouraged the PP to consider how the behaviours would be sustained.

Raising concerns

The review panel enquired about the culture of raising concerns for RDs in AIM. The PP felt there was a good channel of communication that provided the RDs with means of escalation through exception reporting. PP representatives advised that exception reporting was encouraged within the department, and that the St George’s, Epsom and St Helier University Hospitals (GESH) team were responsive to concerns raised. The review panel was pleased that the Guardian of Safe Working (GoSW) was supported by the senior team and felt that issues raise through resident doctors were addressed.

It was reported by the PP representatives that the number of immediate patient safety concerns had consistently decreased within the department since 2022. The PP representatives also informed the review panel that they had implemented safeguards to ensure the accuracy of exception reporting numbers. It was advised that a member of the postgraduate medical education team was asked to work directly with foundation RDs to ensure concerns were being raised.

PP representatives reported good attendance at resident doctor forums (RDFs), which enabled RDs to raise concerns. The review panel was pleased to hear of instances where RD feedback resulted in departmental changes including the addition of peer support on night shifts. It was noted by the PP that there was a current group of confident RDs who were happy to raise concerns and contributed to the success of this process. The PP representatives advised the review panel that they intended to seek daily feedback from the existing RDs on a range of areas including consultant behaviour, performance and clinical decision making and teaching which they would feed back to consultants in a supportive manner.

The review panel asked how the PP representatives planned to reach out to new RDs to reinforce confidence in raising concerns. PP representatives advised that information on raising concerns was included in one of the first slides of the departmental induction presentation, and that members of the Executive team would speak about its importance. PP representatives further reported that the issues had been discussed at board level, and that their action plan for educational improvement would be monitored through the Medical Workforce team, which will produce a monthly report that will be forwarded to the Senior Leadership team to ensure accountability.

Wellbeing

The review panel enquired about how the foundation doctors in AIM would be supported during this cultural shift and period of educational improvement. The PP representatives informed the review panel of a two-part plan to be introduced with its foundation in additional mentorship. It was advised that in addition to existing consultant educational supervisors, foundation doctors would be assigned a registrar for additional support and educational supervision, who could raise concerns on behalf of RDs. It was further stated that RDs would receive on the job teaching mentorship from Internal Medicine Training (IMT) or Acute Care Common Stem (ACCS) RDs.

PP representatives advised that additional support could be provided through existing channels including RDFs. It was suggested that a foundation learner representative could be created to report on these changes for each RDF. The review panel considered these suggestions positive initiatives and encouraged the PP to implement these ideas.

Rota design

The review panel asked the PP representatives to clarify the rota design for the Acute Medical Unit (AMU) and the medicine on-call. PP representatives outlined that there were 2 foundation year 1 (FY1) RDs who were based in the AMU. However, PP representatives advised that they were on the medicine on-call rota. It was further confirmed there were no current foundation year 2 (FY2) RDs attached to the AMU and that any FY2 RDs working in AIM were working on the medical on-call.

The review panel enquired whether the foundation RDs understood the rota formatting and if they found the system to be confusing. It was reported that they had not received any negative feedback from RDs, however the PP representative acknowledged that they had not sought this feedback specifically.

PP representatives informed the review panel of the internal processes involved in rota design of AIM. It was reported that the rota had a rolling format, with input from the administrative team, training learner representatives, service managers and ACCS RDs. It was further outlined that several areas exist within the AIM department including the AMU and Same Day Emergency Care (SDEC).

The review panel was informed that the rota design allowed for appropriate staffing levels. The PP representatives reported that FY1 RDs were encouraged to stay upstairs in the AMU where they were directly supervised by 2 AIM consultants. It was further stated that this system ensured FY1 RDs were not treating patients outside designated clinical areas (so-called ‘corridor care’).

PP representatives advised that the rota operated with a flexible design to ensure that RDs could gain experience in all areas of AIM. The PP representatives recognised that previously ACCS RDs received limited education opportunities as the rota assigned them to work exclusively in the Emergency department (ED). It was highlighted that this current rota was designed to ensure that RDs could move flexibly between multiple areas to resolve this issue. PP representatives outlined future plans to adjust rota timings to conform with other department start times.

Educational opportunities and educational governance

The review panel enquired about the educational opportunities of RDs in AIM. The PP representatives acknowledged issues with bedside teaching and confirmed that RDs reported it was not occurring. PP representatives were unsure why this was as they reported providing instructions and guidance on the process and had asked consultants to improve in this area. The review panel suggested that consultants may benefit from clearly highlighting moments of teaching to ensure that RDs recognise educational opportunities.

PP representatives informed the review panel that RDs experienced difficulties with attending teaching sessions. PP representatives advised that many RDs were unable to release themselves from clinical duties to attend sessions. It was further reported that if RDs were able to attend these sessions, they would stay behind, and finish shifts later due to the large workload and clinical responsibilities.

However, it was noted that some success had been observed with the introduction of daily huddles within AIM. PP representatives advised that they had introduced a daily huddle with consultants at 9:30am which allowed for RDs to be assigned to different areas at times of high workload. PP representatives reported that allocation of RDs to areas of learning had improved, but they were still issues within gaining experience in some areas.

PP representatives advised the review panel of the establishment of a Medical Education Leadership team and proposed avenues where they could improve educational governance in AIM. PP representatives described that the team operated under a group of 5 senior clinicians and could be utilised to review the educational portfolios of Locally Employed Doctors (LED) and RDs to ensure they were meeting curriculum requirements.

Educational supervision

The review panel enquired about the support and educational experience for RDs in internal medicine training (IMT) stage 1 and IMT stage 2. The PP representative reported that RDs were allocated an educational supervisor located outside of the AIM department.

The review panel asked about the current processes for selecting educational supervisors and how the PP representatives were ensuring that appropriate time was allocated in their job plans. PP representatives confirmed that the Director of Medical Education (DME) ensured that supervisors were trained in educational supervision and had an allocated education portfolio. PP representatives advised that as part of the improvement work when recruiting new consultants, preference would be given to those with an interest in education.

PP representatives informed the review panel of the job planning allocation in AIM. It was reported that education supervisors were allocated the time recommended for job planning in line with NHS England guidelines. PP representatives further advised that they monitored the performance of educational supervisors by tracking if they were spending time on training in line with their job plans and ensuring attendance at educational supervisor training.

However, it was noted that consistent negative feedback had been received from RDs on educational and clinical supervision. PP representatives acknowledge that RDs had difficulties completing initial supervisor meetings and more work was needed to improve this. The review panel suggested that following negative feedback from the 2025 General Medical Council (GMC) National Training Survey (NTS), the PP representatives should review their process for selection of educational supervisors.

Culture and clinical supervision

PP representatives acknowledged that difficult consultant behaviour was an ongoing challenge to educational improvement. It was noted that while reports of bullying behaviour was minimal, consultants had been observed challenging RDs in an inappropriate manner when questioned which had impacted confidence to raise concerns.

PP representatives also described further instances of inappropriate behaviour from consultants. It was reported that consultants were observed leaving abruptly during board rounds or informing the RDs that they must complete board rounds without support. PP representatives also described difficulties in finding some AMU consultants during afternoon shifts. PP representatives acknowledged ongoing issues with consultant visibility. It was reported that some consultants were starting their shifts late and were similarly leaving early. The PP representatives advised that they previously introduced a clock-in, clock-out system which had initial impact, however when this system was removed the behaviours resumed.

Areas that are working well

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Lauren Thomson, Education Quality Coordinator, NHS England-London
Review lead: Bhanu Williams, System Dean South West London, NHS England-London
Date approved by review lead: 6 August 2025

NHS England authorised signature: Elizabeth Carty, Postgraduate Dean, NHS England- London
Date authorised: 29 August 2025

Final report submitted to organisation: 29 August 2025