Executive summary

Through the feedback provided by resident doctors, it was evident that substantial improvements have been made within General Internal Medicine over the past 18 months and areas of concern that had been raised in the previous review have been addressed. There was good representation from a broad range of resident doctors who provided valuable insights into their training experience.

The below are highlights of areas that are working well: 

• The trust benefits from a positive and proactive education team.
• There is a clear responsiveness to concerns raised. Most issues are acknowledged and either addressed, or there are credible plans to do so.
• Various resident forums have raised important issues serving as a catalyst for positive change.
• The trust was described as having a welcoming and supportive culture, contributing positively to the work and learning environment.
• Support was reported as readily available for junior clinicians.
• Rotas are published well in advance and are rarely changed at short notice
• There was general awareness of educational work schedules, although, they are not always utilised to their full potential.
• On call rotas for new starters are tailored to ensure doctors receive appropriate inductions before undertaking clinical duties.
• Some wards, particularly in Cardiology and Geriatric Medicine, were noted for providing good inductions and delivering good speciality focused teaching.
• Staff mentioned as going ‘over and above’ included a consultant in Acute Medicine and a consultant Cardiologist

Areas that would improve the learning experience further include the following: 

• Ward workloads are hindering access to education and training, especially in Gastroenterology, where resident doctors often struggle to attend teaching and other training opportunities.
• Limited access to IT and a shortage of desk space in clinical areas makes it difficult for doctors to complete notes and documentation.
• The induction process should be reviewed particularly at ward level. There is a need for a more structured, ward specific, speciality-based and role-based specific induction to better support resident doctors.

During the visit, the panel identified two immediate mandatory requirements. These related to ongoing challenges in the working relationship with the emergency department (ED) and the need for a review of the post-admission patient tracking process.

Overall, the resident doctors described the hospital as friendly and supportive. The Trust demonstrates a strong awareness of the issues it faces and is actively working to address them. The Trust leadership has shown willingness to reflect on feedback and adopt a solution-focused approach. There is a clear commitment to improving consistency, strengthening oversight, and ensuring that all doctors, regardless of start date, receive a high quality, timely, and well-documented induction experience. In general, resident doctors would recommend the hospital as a place not only to learn but also to receive care and treatment.

Next steps

The trust has demonstrated a commitment to improving the training experience, and NHS England are assured that the areas for improvement highlighted above, along with the additional recommendations in this report, will be carefully reviewed and addressed.

Based on these assurances, it is recommended that the trust be de-escalated from Intensive Support Framework (ISF) category 2 to ISF 1.

Review overview

Background to the review

The 2023 General Medical Council (GMC) National Training Survey (NTS) and the National Education and Training Survey (NETS) identified several areas within General Internal Medicine (GIM) where resident doctor feedback at the hospital fell below the national average. These results raised concerns about the quality of the learning environment for resident doctors.

In response, a learner educator meeting was held in December 2023 to explore the issues in greater depth and to begin addressing the concerns raised by resident doctors. During this meeting, further challenges were identified, including several patient safety concerns. As a result, the trust was required to implement an improvement plan to strengthen governance, enhance the training environment and ensure robust measures were in place to improve the learning environment.

A follow-up quality review was carried out on 23 May 2025 to evaluate progress made since the initial findings and to assess the impact of the changes implemented, to improve the training experience in GIM.

Who we met with

Learners                          

• Foundation Doctors in General Internal Medicine, General Practice resident doctors, IMT Stage 1 Doctors, and Group 1 Medical Registrars in General Internal Medicine

Educators                         

• Educational and Clinical Supervisors  

The Education Team        

• Educational Leads

Review panel

• Education Quality Review Lead, Head of School (WM Medicine) – Professor Phil Bright
• Deputy Head of School (WM Medicine) – Dr Gordon Wood
• Associate Postgraduate Dean – Dr Ellen Knox
• Foundation School Director (South) WM – Dr Murthy Narasimha
• Deputy Quality Manager – Joycelyn Boyce, NHS England

Review findings

Induction

All foundation doctors received both trust wide and departmental inductions and rotas were provided at least eight weeks in advance. Most found the induction sufficient to prepare them for day-to-day duties, however, there was no specific on-call induction, and not all F1 residents had participated in assistantships. On the whole, Gastroenterology resident doctors described the departmental induction as structured and inclusive.

In the General Practice, IMT Stage 1 Doctors and Group 1 Medical Registrars session, all confirmed receiving a trust induction which was generally viewed as comprehensive and effective. Importantly, safeguards were in place to ensure they were not placed on-call before appropriately inducted. However, the quality of the departmental inductions varied significantly with some doctors reporting a lack of processes, escalation routes and named contacts. Educational supervisor and resident doctor induction meetings were not at the required standard; it was unclear whether all Group 1 resident doctors had a defined GIM educational supervisor and clear GIM inductions were not apparent.

It was further reported that the shadowing week (Foundation Y1) was underutilised and could be better structured to support the doctor’s readiness for clinical duties, especially for out of hours.

For those in IMS1 and higher, Group 1 training, the induction needs to include a discussion of the expected experience at the CiP level and an indication as to what evidence should be collected, again at the CiP level.

Rotas / workload

Workloads for Foundation resident doctors were described as variable and manageable, with access to break even during busier shifts. The second on-call shift, particularly at weekends covering the wards, was highlighted as stressful, especially when F1s were not paired.

GP, IMT Stage 1 Doctors and Group 1 Medical Registrars described workloads as heavy, particularly weekend shifts which impacted rest, and limits the ability to access educational opportunities. IMS1s expressed concerns over reduced acute take exposure due to ward commitments and the requirement for maintaining minimum staffing levels on the ward.

Learning opportunities

The overall experience of foundation training at the trust was described as broadly positive, although, there appeared to be a significant variation in learning experiences.

Doctors highlighted good access to senior support, a welcoming atmosphere in most departments, and structured supervision that met the doctors’ expectations. Resident doctors felt supported during routine working hours and had confidence in escalation procedures when issues arose.

GP, IMT Stage 1 Doctors and Group 1 Medical Registrars reported that departmental teaching was generally regular, well organised and valued. Opportunities for resident-led teaching were also welcomed. However, competing clinical demands meant that attendance at some sessions were inconsistent. GP resident doctors often found it difficult to attend departmental teaching due to rota conflicts. Access to outpatient clinic experiences were restricted due to service pressures and lack of physical space.

Resident doctors in IMY2 should have the opportunity to act-up as the medical registrar, and feedback on their performance in managing the acute unselected take (rather than just clinical ability) used as the primary determinate of whether they have met the requirements for clinical CiP1.

Handover

All resident doctors felt that handover was not being used as structured learning opportunities. There was no training for those leading the handover. There was no practice in identifying individual learning needs at the start of a shift or of using learning opportunities within the handover.

Supervision

Foundation doctors reported that supervision and senior support works well and they can access help when needed, especially in the Acute Medical Unit and post take ward rounds, which is a significant improvement from the previous review in 2023. 

GP, IMT Stage 1 Doctors and Group 1 Medical Registrars generally found their supervisors to be accessible, supportive and committed to development. Many valued the opportunity to raise issues and receive guidance. However, supervision practices were reported as inconsistent across departments. Some doctors had limited contact with their supervisors prior to starting, and curriculum planning was not always prioritised. Feedback was commonly described as generic and lacking in developmental value and a portfolio review identified delays and gaps in the induction process and educational meetings, especially within GIM.

Those in IMS1 (IMY2 and 3) and those in Group 1 higher training need feedback on their performance in the role of medical registrar that focuses on non-clinical aspects of the role. This should be done via the ACAT form.

It was noted that initial meetings with educational supervisors were not well recorded and lacked detail of the expected experience against each CiP alongside an indication of the expected evidence that should be gathered by the resident doctors. This detail should be documented either on the induction form or in a separate document stored in the resident’s portfolio library, with a link to it in the induction document. These initial plans should be reviewed and updated at monthly educational meetings.

Exception reporting

There was good knowledge of escalation routes with foundation doctors, and awareness of exception reporting and how and when to exception report. Awareness of the sexual safety policy on the other hand was uneven. The overall culture was seen as one in which issues could be raised without fear.

GP, IMT Stage 1 Doctors and Group 1 Medical Registrars reported a variable understanding of exception reporting processes, particularly among new starters. While most doctors were aware of the system, there was uncertainty around when and how to use it, limiting its effectiveness as a tool for raising workload and training concerns.  The lack of effective use of educational work schedules resulted in a lack of awareness about reporting issues with training via this route.

Facilities

Older wards were described as cramped and poorly designed, contributing to workspace limitations and compromising patient confidentiality. The absence of private areas for sensitive conversations was repeatedly raised as a concern. IT access was also reported as an issue, with a shortage of functioning computers frequently cited.

Access to a vending machine and the ability to take breaks were viewed positively, however the ability to access a working computer is a challenge.

Culture and behaviour

There was a general sense from Foundation resident doctors that their input was valued and that they had been given the opportunity to share their experiences constructively and that these were taken on board to work towards improving the working environment. They described the trust as a generally safe and supportive environment.

While not all foundation doctors were directly aware of previous improvement plans, there was a consistent perception that improvements have been made across several areas. An example is the re-introduction of teaching sessions. 

When asked if they would recommend the trust as a place to train, half the doctors present said they would recommend the trust. Inconsistencies in teaching, IT access and on-call workload management were reasons for not recommending their placement.

When the same question was asked around the trust as a place to receive care and treatment all but one said they would recommend the trust as a place to receive care.

A strong culture of respect and inclusion was a theme that ran through the GP, IMT Stage 1 Doctors and Group 1 Medical Registrars feedback. They felt empowered to raise concerns and confident that their voices were heard. There were no reports of bullying, harassment or discrimination, however, two trainees said that incident reporting (Datix) had been used in a punitive way, which could potentially undermine a learning focused experience.

Most doctors described their working environment as positive, with supportive colleagues. However, unresolved concerns in some departments (especially between Emergency Department and Acute Medical Unit) and workload peaks (especially out of hours ward cover), continue to affect the working experience.

When GP, IMT Stage 1 Doctors and Group 1 Medical Registrars were asked if they would recommend the trust as a place to train, two thirds of resident doctors said they would currently recommend the trust. Their reluctance appeared to be linked to inconsistent supervision, limited access to learning and variable departmental experiences.

When asked as a place to receive care and treatment only two resident doctors said they would recommend the trust for care and treatment. Concerns included fragmented communication, care co-ordination and perceptions around patient safety.

Communication between emergency and speciality teams was identified as a weak point. Poor interdepartmental communication, unclear clinical ownership, and inappropriate prescribing were raised as concerns. These issues were linked to staffing pressures and insufficient shared understanding of responsibilities.

Educator supervisor feedback

Trainers reported feeling well supported in their roles as educational and clinical supervisors, with the education team praised for its accessible guidance, regular communication and structured support. Most trainers felt confident in their responsibilities, with appropriate resources and clear escalation routes, such as college tutors, the education team and the medical director.

Educational development was broadly supported, with most trainers attending internal sessions such as “Train the Trainer”.  Protected time was generally respected, although access to external training remained limited due to ward pressures. Stage 1 and Group 1 GIM trainers reported receiving curriculum updates in all the curricula they were supervising in the last 12 months, reflecting a shared commitment to improvement. However, the process for tracking curriculum updates and the criteria for assigning trainers to individual resident doctors were not clearly defined.   

Trainers felt their roles were recognised by the Trust, evidenced by job planned supervision time, ARCP involvement, and inclusion in relevant communications. However, it was unclear whether trainers were informed of and encouraged to attend national recruitment.

Educational supervision time was included in job plans, though recognition for supervising locally employed doctors varied. It was not always apparent whether trainers used their allocated time effectively but noted that high clinical demands impacted on their ability to engage in external development activities.

There is a disconnect between how trainers perceive the quality and structure of their training and how resident doctors actually experience the training they receive, particularly during the acute take. While trainers may believe the current setup provides adequate learning opportunities, this was not always the perception of the resident doctors.

Education team feedback

Commendable progress has been made in developing a structured and comprehensive induction programme designed to prepare doctors for clinical duties. The education team reported that induction is delivered at trust-wide, specialty, and departmental levels, with attention given to on-call readiness and site-specific orientation. Feedback mechanisms for residents appeared well established, including QR-coded forms and a trust-wide survey, with results informing continuous improvement.

There was evidence of leadership engagement and effective lines of communication with doctors in training. The newly appointed Director of Medical Education (DME) plays an active role in maintaining dialogue through regular forums, drop-in sessions, and ward visits and prior to their appointment the medical education team had maintained this structure. Whilst this reinforces a culture of support and openness, recent observations suggest that the induction process is well-conceived in principle, yet its delivery is not always consistent between medical specialties.

Areas that are working well

Areas for improvement

Immediate mandatory requirements

Recommendations

Report approval

Report completed by: Joycelyn Boyce, Deputy Quality Manage
Review lead: Phil Bright
Date approved by review lead: 4 July 2025

NHS England authorised signature: Prof. Andy Whallett, West Midlands Postgraduate Dean
Date authorised: 18 July 2025

Final report submitted to organisation: 6 August 2025