Executive summary

This was a follow up review visit. There was a previous visit to cardiology at Great Western Hospitals NHS Foundation Trust (GWH) in November 2024. The first visit was carried out in response to concerns identified from the GMC National Training Survey and the NHSE National Education and Training Survey, both 2024, as well as concerns identified through local quality processes in the South West.

During the last visit, there were a number of mandatory requirements for areas to improve and a follow up visit planned to review these at 6 months.  The requirements for improvement included;

• enabling access to clinic to achieve curricular requirements
• safe, thorough and reliable induction programme for clinical and IT processes, ensuring prior competencies passported
• senior supervision to be clearly identified and available throughout the working day

Overall, the panel noted improvements have been made, and some of the requirements for improvement have been addressed. The trust provided a comprehensive update, and the energy and positivity of all to develop an excellent learning environment was evident.

An improvement has been made on the induction programme and the resident doctors (RDs) agreed with this.

RDs have been given the opportunity to attend other specialty clinics but there is still minimal access to cardiology clinics.

The addition of a clinical fellow and locally employed doctor has helped to improve middle grade support for RDs but has now left. At this point, improvement is needed to maintain minimum levels required for adequate supervision.

The panel would like to thank the DME and department for the work to jointly continue to improve the experience for learners.

The panel have provided three Mandatory Requirements at the end of this report and propose continuing routine school led proactive and reactive quality monitoring processes such as through quality panel and NETS/NTS data, with a further visit in 6 months.

Review overview

Background to the review

This was a follow up review visit.  There was a previous visit to Cardiology at Great Western Hospitals NHS Foundation Trust (GWH) carried out in November 2024.  The previous visit was carried out in response to concerns identified from the GMC National Training Survey and the NHSE National Education and Training Survey, both 2024, as well as concerns identified through local quality processes in the South West.

Who we met with

Learners

• IMT1 (Internal Medicine Training)
• A previous IMT1
• Both represented all Cardiology Resident Doctors
• Subsequent feedback from IMT1 has been incorporated into this report

Educators

• Clinical Lead / Consultant
• Educational Lead / Consultant
• Both represented all Cardiology Consultants

Education team

• Director of Medical Education
• Medical Education Manager

Review panel

• Associate Dean for Quality – Secondary Care
• Associate Dean for Quality – Primary Care
• Head of School (Foundation)
• Head of School (Medicine)
• Quality of Education and Training Officer
• Patient and Public Representative 

Review findings

Learning Environment and Culture

The RDs found induction to be good; this is a definite improvement since the first visit.  The RDs were shown around the department and provided with a handbook.  The presentation from the DME also demonstrated the department induction has improved; it is consistent and there are 3 colleagues who run it (2 out of 3 colleagues always make sure they are present).  The Trust induction to IT has been difficult in the past due to stretched IT teams and limited space. RDs were required to book on to a training session.  From February 2025, a new system has been trialled: – the PGME team book RDs into training sessions, in collaboration with department rota leads.  This has resulted in better rates of attendance.

The DME reported that there have been no recent exception reporting submissions for cardiology within the last 30 days for additional hours, missed educational opportunities or immediate safety concerns.  The RDs felt the culture is stopping RDs from completing exception reports and Datix (a system used to capture incident reporting), particularly in being questioned over why an exception report has been submitted.  The Trust has appointed a new Guardian of Safe Working to manage the exception reporting system.  No local changes will be made to the process by the Trust until national changes have happened, which are planned for August/September 2025.  The Trust confirmed that all RDs have been emailed to remind them of exception reporting and to encourage their submission.

The Trust have reviewed Datix submissions from Mercury ward over a 6-month period and could find no harm to patients as a lack of senior support / supervision identified by the department. We heard from a learner that Datix regarding staffing was not welcomed, as this creates more work for supervisors.

The culture of a few consultants makes it difficult for RDs to raise any concerns or ask for support, which could affect patient safety. 

We were told that incivility from isolated individuals remains an issue and has been formally escalated outside this review via normal trust processes.

In subsequent feedback via the IMT TPD the RDs commented on a good learning experience from coronary care, where they are able to take SDT and leave. However, they are persistently understaffed on the Mercury cardiology ward.  There is a lack of supervision and support from consultants.

The teaching culture is variable between consultants. There is no departmental teaching. Not allocated to clinics and difficult to get off the ward for this. Arrangement of consultant cover on Mercury makes it difficult to attend teaching.

There are negative responses from the department when exception reports are submitted. The response to inquiry about clinics at induction that there is no access to clinics was disheartening at the start. It was explained that this is due to unavailability of clinic rooms yet IMT RDs are frequently interrupted to complete prescriptions for nurse practitioners in those rooms.

Educational Governance and Commitment to Quality

The College Tutor role has been advertised several times but there has been no success with an appointment to replace the current College Tutor, who is also Head of School for Medicine.  The plan now is to develop a deputy role to work with the existing College Tutor.  The long-term plan will be the hope for the deputy to take over the College Tutor.

The Trust emphasised that the PGME team are going above and beyond and working at full capacity.  Protection of tariff for education delivery and management is very important.

Developing and Supporting Learners

Access to middle grade support can still be challenging for RDs, although the registrars are helpful despite busy schedules.  On Mercury Ward, there has been a clinical fellow (middle grade locally employed doctor) on the ward every day and some extra Foundation Doctors which has helped.  There is no clinical fellow on CCU but there are regular consultant and registrar ward rounds.

The RDs felt more support was required, particularly on Mercury Ward, which is mostly run by F1s and the more junior medical staff.  There are many complex or multi-morbid patients, and some patients are only seen by F1s, despite the presence of the middle grade.  The RDs had concerns about the lack of senior support from a dedicated consultant on Mercury ward.  There are separate consultant ward rounds at different points in the day.  If a consultant is ill, the RDs are not aware.  Sometimes patients are not reviewed by consultants in a weekly timescale.

The Trust highlighted that they now have a DECT phone so RDs can contact the middle grade locally employed doctor if they are not physically present on the ward.  When the locally employed doctor is away, the expectation is for cardiology consultants to cover the patients.

The Trust explained that with current staffing, it is not possible to have a consultant of the week for Mercury ward as there is for CCU.   There is an escalation policy that has been circulated and included at induction.

Delivering Curricula and Assessments

During the last visit, it was reported that IMT RDs were not receiving their mandatory curricular requirement of weekly outpatient clinic time and this was mostly due to an issue with physical space in the hospital. 

Both trust and RDs confirmed that space is still an issue. The RD’s reported that they are not offered clinics in cardiology but are offered the chance to book onto clinics in other specialties. The clinical lead has identified a room that could be used long term to be transformed into a workspace to free up a clinic room that is currently being used for reporting.

Some IMTs have joined nurse-led cardiology clinics but would prefer consultant-led clinics.In addition, the IMTs are asked to prescribe for those nurses, for patients that they have not seen.

The Trust noted that staffing to release RDs to go to clinics is also a challenge. 

The RDs do not receive consultant-led teaching and very few registrar-led teaching sessions.  They believe that this would prepare them better for their work in cardiology and to provide better care to their patients.  They were complimentary about bedside teaching from a few consultants and the variety of cases they see in CCU and Mercury ward.

The RDs find it difficult to attend formal teaching as consultants are unfamiliar with the teaching programme schedule and so there are conflicting demands.  The PGME team are working to formalise the expectation for the department to release Foundation Years to teaching, but it is not yet robust.

From August 2025, the Trust will have a Clinical Education Fellow based in the clinical area on Mercury ward (50% funded by the department and 50% by PGME).  For the PGME funded part of the post, they are predominantly there to help with Foundation Years within the clinical area, oversee the teaching timetable and coordinate it.

Consultants are willing to complete work-based assessments (WBAs).  Registrars and clinical fellows are also helpful in completing WBAs.

Developing a Sustainable Workforce

The RDs felt the department is often at or below minimum medical staffing levels in terms of RDs, and locum/float cover is frequently required.  The RDs have escalated this concern via the Clinical Lead a number of times with limited success and would like clarity on the minimum staffing number required.

The locally employed doctor (middle grade) has recently moved to another post and there will be a new locally employed doctor starting within 3 months.  All efforts to pre-empt the gap in the post was restricted by current restrictive recruitment processes in the current financial environment.  This has led to a short-term gap, but there should be improvement once the new appointment has started.

From August 2026, there will be an additional FY2 on Mercury Ward and a hope to employ a locally employed doctor at FY2 level from August 2025.

For middle grade support, there will be an additional Specialty Trainee (ST)tier 2) and Chief Registrar in cardiology from August 2025.

Areas for improvement

Mandatory requirements

Report approval

Report completed by: Ilana Langdon, Associate Dean for Quality, Will Wallage, Associate Dean for Quality (Primary Care)
Review leads: Ilana Langdon, Associate Dean for Quality, Will Wallage, Associate Dean for Quality (Primary Care)
Date approved by review lead: 3 July 2025

NHS England authorised signature: Geoff Smith, Regional Postgraduate Dean
Date authorised: 5 August 2025

Final report submitted to organisation: 26 September 2025