Executive summary

NHS England Workforce Training and Education South West carried out a triggered quality review in response to concerns identified from the GMC National Training and NHSE’s National Education and Training Surveys 2024 as well as concerns identified through local quality processes.

The high-level concerns identified related to induction to the Trust and placement being of variable quality, in terms of being reliably delivered at the point of starting the placement, and in the quality and completeness of content.

The training for more junior resident doctors in both acute medicine and cardiology was found to be of variable quality, with some areas of very good training and others where the learning experience and access to senior input into clinical care were poor. 

On the Coronary Care Unit, training is described as high quality.  However, on Mercury ward (cardiology and care of the elderly), with access to more senior staff described as difficult for foundation-level resident doctors, leading to poor training and supervision and a potential threat to patient safety. IMT (Internal Medicine Training) resident doctors in cardiology are not receiving their mandatory curricular requirement of a weekly outpatient clinic (averaged across the placement).

In acute medicine, excellent training is available but there are too few supervisors, having 8-10 supervisees each; the panel were told that 50% of the consultant posts are vacant. The panel were told that the acute medicine team manage patients throughout a long inpatient stay, compounding high workload and managing care that is not appropriate for acute medicine training.

Ward-based clinical supervision and training for the most junior resident doctors in cardiology is needed.  This has been a focus for development following our intelligence reviews with the PGME (postgraduate medical education) team with no progress; senior trust management involvement in this process is needed. The Head of School of Medicine is also College Tutor for Internal Medicine Training, because no successor has been found, giving a conflict of interest.

The findings were communicated to the senior medical team at the trust, including the Director of Medical Education, the Chief Medical Officer and the Associate Medical Director, and subsequently to the NHSE South West regional clinical quality team, in regard to the service clinical quality issues.

Review overview

Background to the review

Multiple data sources, including the General Medical Council National Training Survey, National Education Training Survey and Regional Quality Panels, indicated that Great Western Hospital NHS Foundation Trust was not providing adequate quality of education and training across a number of programme groups in cardiology and acute medicine, despite early intervention by the relevant Schools and quality team input. A reluctance to welcome NHS-naive resident doctors had been noted and has already been the subject of a prior intervention from the quality team on 21 August 2024. After discussion at the Quality Scrutiny Oversight Group 11 September 2024, this visit was arranged to assess areas of concern, particularly around the quality of supervision.

Who we met with

Resident doctors from the following programmes:

• F1 (Foundation 1)
• F2 (Foundation 2)
• GPST (General Practice Speciality Training)
• IMT (Internal Medicine Training)

Educators

• Consultants, College Tutor

Education team

• Director of Medical Education, Associate Medical Director/Academy Dean.

Review panel

• Associate Deans for Quality – Secondary Care and Primary Care
• Co-Training Programme Directors for Internal Medicine Training
• Foundation School Director
• Lay representative
• Quality of Education and Training Officer

Review findings

Learning environment and culture and Educational governance and commitment to quality

Induction in cardiology and acute medicine is variable.

An IMT doctor on cardiology rotation said that their trust induction was very useful and informative. However, another said that their first day was on one of the wards for an hour, after which they went through a PowerPoint presentation.  Another IMT doctor’s trust induction was similarly poor, with an hour-long PowerPoint presentation on about five or so IT systems. After this the Resident doctors were expected to know how each system worked. There were supposed to be talks from colleagues who had done the new starters’ jobs or similar, but these were discontinued for unclear reasons.

A resident doctor described being on the coronary care unit (CCU) when neither of the two of them on that shift had been properly trained on how to do discharges on the IT system which made it very frustrating and affected patient flow. All new resident doctors are required to do online training, but some felt this was not made clear.

There is variable specific support for new to NHS doctors described, there are areas of excellence with a specific IMG lead, but due to a combination of high workload and insufficient time for the IMG lead this is not consistently delivered.

Developing and supporting learners

Most resident doctors present said that they were assigned their supervisors in good time.  Resident doctors in acute medicine said that the registrars and consultants were happy to complete work-based assessments (WBA) or supervised learning events (SLE) and were very approachable, but that there was often delay or sometimes even a failure to complete the assessment because of workload pressures for the senior colleagues.

One of the resident doctors in cardiology had to change their ES/CS (educational supervisor/clinical supervisor) due to significant interpersonal issues. The panel was told that this was handled swiftly and efficiently by the supportive Foundation Programme Director, and the resident doctor in question now has very good, effective supervisors.

A resident doctor in acute medicine told the panel that they feel respected.  However, they feel that their clinical supervision is inadequate at times due to workload of others within acute medicine.

The panel heard that resident doctors in cardiology often find it difficult to access consultant and registrar colleagues when on Mercury ward (half geriatrics/half cardiology), as the consultant tends to leave as soon as possible after seeing patients. There is a middle grade trust grade doctor allocated for supervision in the morning, who leaves at 12 for other cardiology areas and is then unavailable for the rest of the day.  Another Resident doctor said that when unable to get assistance from the Mercury middle grade doctor for urgent matters, which is reported to have happened on more than one occasion, they seek help from other seniors, either registrars on CCU, in clinic, or the consultants in the cardiac catheter lab, which in an urgent situation can feel stressful. Resident doctors also mentioned reluctance from some consultants if they were approached about a patient under the care of another consultant. Mercury ward is chiefly staffed by Foundation 1 and 2 Resident doctors after 12 noon, which can feel unsafe to those doctors who worry that they do not yet have the necessary level of competence to manage the complex medical issues presented without support. 

Resident doctors described the CCU as well supported, with regular ward rounds.  It is described as a “fantastic area for teaching and training”.

The College Tutor for IMT is the Head of School of Medicine, giving a conflict of interest.  The College Tutor role has been advertised several times without success; steps to ensure successful recruitment to key educational governance roles should be a matter of priority to the trust.

Developing and supporting supervisors

Some of the supervisors in acute medicine that the panel spoke with have as many as ten Resident doctors to supervise and this is not accounted for within their job plans. Communications after the meeting were received emphasising the high workload for consultants within acute medicine, and their desire to provide better support and supervision than that which is currently possible.  Supervisors describe feedback as demoralising and demotivating. 10 of the 23 posts in the Acute Medicine rota are filled by Locally Employed Doctors (LED). Consultants have fed back that supervision of new to NHS doctors (LED or resident doctors) takes a “disproportionate amount of time”.  They articulated a need for additional support for new to NHS doctors, but wish this to come from NHSE WT&E.

One of the consultants described that patients cared for by the acute medicine team are not transferred to medical specialities after their admission into acute medicine.  Only one third of patients are within 72 hours of admission, and one third are more than 2 weeks into their admission. This has a significant impact not only on workload but also on the ability to teach resident doctors on cases appropriate to the speciality of acute medicine. The consultants also believe that this inappropriate work is one of the reasons that they have been unable to recruit, with 8.4 consultant vacancies, and may affect patient flow and discharge as patients are often not managed by an appropriate specialist.

On Mercury ward, supervisors said they need more middle-grade resident doctors to be able to support to a sufficient level during the full normal working day. This would require a minimum of two in post, to allow time on wider cardiology areas of practice and to cover leave. Some consultants said that they did not believe there was any concern around patient safety on Mercury ward and seemed unsighted on the difficulties and poor supervision that the resident doctors were describing.

Delivering curricula and assessments 

IMT resident doctors are not receiving their mandatory curricular requirement weekly outpatient clinic time. Supervisors said this was an issue of physical space in the hospital.

Developing a sustainable workforce 

The panel heard from some supervisors that additional time spent on supporting less confident and NHS-naive doctors contributes to high workload pressure within the departments.

The trust lead for Equality, Diversity and Inclusion is doing very good work in helping doctors new to the NHS but according to supervisors, the Director of Medical Education and the lead herself, has insufficient job planned time to achieve this consistently as this cohort has increased.

Areas that are working well

• Training on the Coronary Care Unit

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Ilana Langdon, Associate Dean for Quality
Review lead: Ilana Langdon, Associate Dean for Quality
Date approved by review lead: 15 January 2025

NHS England authorised signature: Prof. Geoff Smith, Regional Postgraduate Dean

Date authorised: 17 January 2025