Executive summary

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

During the last visit, there were two mandatory requirements for improvement and a follow up visit planned to review these at 6 months.  The requirements for improvement in acute medicine included; 

• enabling clinic attendance to achieve curricular requirements
• safe, thorough and reliable induction programme for clinical and IT processes, ensuring prior competencies passported

At this visit, the Trust provided a positive and comprehensive presentation; the panel were impressed with the efforts and improvements made since the last visit.  All requirements for improvement had been addressed.

The panel were particularly impressed with the AMU department’s specific Resident Doctors Forum (RDF), which creates an open space for listening to resident doctors, enabling concerns to be heard, investigated and resolved with feedback on actions, using a “you said, we did” approach.

There are excellent educational initiatives in the Acute Medicine department, including weekly departmental teaching, AIM simulation sessions and opportunities for clinical procedures.  The use of “Signal” app allows rapid sharing of the opportunity to see interesting cases in the department for teaching, workplace-based assessments and clinical procedures.

The panel recognise the difficulty of sustaining the acute medicine department’s improvements and emphasise the need for continued resource and substantive recruitment to maintain positive progress.  The need for IMG support is likely to continue to increase in the future.

The panel recognises the benefits of and recommends protected time for supervision of locally employed doctors as good educational practice.  It is important to fund supervision to prevent overburdening existing staff and should be included in business cases for new clinical fellows.

The panel recommend that this setting can return to ongoing routine school-led quality monitoring processes.

Review overview

Background to the review

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

Who we met with

Learners

• Foundation Year 2 Resident Doctor (represented all Acute Medicine Resident Doctors)

Educators

• International Medical Graduate (IMG) Lead for Postgraduate Medical Education
• Clinical Lead
• Deputy Medical Director
• All three represented all Acute Medicine Consultants

Education team

• Director of Medical Education
• Medical Education Manager

Review panel

• Associate Dean for Quality – Primary Care (chair)
• Associate Dean for Quality – Secondary Care 
• Head of School (Foundation) 
• IMT Training Programme Co-ordinator
• Quality Fellow
• Quality of Education and Training Officer 
• Patient and Public Representative 

Review findings

Domain1: Learning Environment and Culture

The resident doctors (RDs) were positive about their experience in the Acute Medicine department, particularly highlighting the very supportive and approachable consultants.

The RDs receive a useful induction when they start, led by a clinical teaching fellow and lead consultant.  The presentation from the DME explained the resident doctors receive a handbook, welcome session, simulation session, a video and an opportunity to meet with the clinical lead if they cannot make any of the sessions.

The Trust induction to IT has been difficult in the past due to stretched IT teams and limited space. Previously, resident doctors received an initial talk followed by a booking on to an IT systems induction session (except for Foundation Year 1, who receive this during their shadowing week pre-start).  From February 2025, a new system has been trialled: – the PGME team book RDs onto the training sessions, scheduling in collaboration with department rota leads.  This new approach has increased the percentage of learners receiving face-to-face IT training from 30% to 53%, with plans to review and improve further in August 2025.

There has been concern from RDs and trainers around the number of patients not being transferred on to medical specialities within 72 hours.  This has impacted on workload and the ability to teach resident doctors on cases appropriate to the specialty of acute medicine. Since March 2025, GWH have implemented a new pathway for Medical Assessment Unit (MAU) with a view to limiting the length of stay in acute medicine to under 72 hours.  We were told that this has helped already, but long-term results are awaited.

The DME confirmed all resident doctors are encouraged to report and escalate any incivility or behaviours of concern.  The PGME team delivered civility and workplace behaviour training at the educators away day in December 2024.

Domain 2: Educational Governance and Commitment to Quality 

The AMU resident doctor forum is run by clinical educational fellows and well attended by resident doctors.  Any concerns raised at the forum are directed to the lead consultant.  All previous concerns have been addressed and a few have been resolved.  Some of these concerns related to workload and rota.

The College Tutor role has been advertised several times but there has been no success with appointment.  The plan now is to develop a deputy role to work with the existing College Tutor (also Head of School for Medicine).  The long-term plan will be for the deputy to take over the College Tutor role in time.  

Domain 3: Developing and Supporting Learners

The resident doctors are appointed clinical supervisors when they start in the department.  They find them very supportive, and it is easy to schedule meetings.  Their educational supervisor usually works outside of the department.

The resident doctors reported that they can fulfil their curricular requirement for clinic attendance.  The department confirmed that they give support for resident doctors to attend specialty clinics.

All trainees are given the requisite time for self-development time (SDT) according to their programme, with encouragement to take time away from the unit.

The IMG lead detailed the comprehensive IMG support process.  Support for IMG doctors starts before they arrive in the country, with a telephone call, induction sessions, the provision of an IMG handbook and welcome video.  Accommodation and pastoral needs are assessed at this stage if required.

Departments are told approximately 2 ½ months before August who they will be expecting and are sent the induction checklist.  This was a new initiative that started last year and will continue.

Upon arrival, IMG doctors’ accommodation and pastoral needs are assessed again, and they are allocated a buddy in the same department to help them settle in.

Regular catch-ups are conducted before they arrive and after to address any specific needs, with one-to-one sessions provided if necessary.

An IMG standard operating procedure (SOP) has been developed this year to highlight who is responsible for each task before the IMG doctor arrives and when they are settling in.  The SOP was presented to the Medical Staff Support Group (MSSG) during the week of this review. The department have received confirmation from the Chief Medical Officer’s (CMO) office that this will go ahead from August 2025.

This year there will be an increase to 2 IMG support fellows, with 50% of their time clinical in AMU and 50% supporting IMG.

This year, all 10 clinical education fellows will have their PGME time cleared to help with any teaching and training that may be identified to support IMGs in their first 2 weeks.

The resident doctors raised concerns with GWH regarding the quality of teaching on Kingfisher Ward.  GWH confirmed the difficult decision was made to temporarily move resident doctors from the ward to the other acute medicine areas due to its current unsuitability for acute medical training with patients staying on the ward for longer than 72 hours.  It is not a permanent decision; there is a plan to develop acute medicine beds as a functional short stay unit.

Domain 4: Developing and Supporting Supervisors

Concerns have previously been raised regarding clinical supervision on the AMU (Linnet Ward) in internal foundation programme quality panels.  We were told that GWH have secured funding to allow a registrar to remain on Linnet Ward throughout the day for clinical supervision.

In the previous visit the panel found that there were too many resident doctors being supervised by individual consultant supervisors.   Some consultants were reporting being a supervisor for up to 10 resident doctors but this did not match with the PGME team records. The PGME team  investigated further to clarify the  situation.  There is one consultant who may have 5 resident doctors and another with 4 resident doctors.  However, some consultants are also supervising locally employed doctors.  Funding for job planned educational supervision is sent to the department but does not cover funding for locally employed doctors.  However, it should be recognised that supervision for locally employed doctors is important and will take time that should be recognised within job plans. PGME have a strategy to increase the number of educational supervisors across GWH.

Domain 5: Delivering Curricula and Assessments

The resident doctors have had a positive experience with the supportive and approachable clinical teaching fellows who organise weekly AMU department teaching and SIM sessions for the resident doctors.  The department teaching has been good and there is room to learn and build up their portfolio.  The resident doctors appreciate the departmental teaching sessions where the teaching fellows liaise with consultants from other medical departments.

The resident doctors sometimes find it challenging to attend Foundation teaching.  Acute medicine has a heavy patient intake, the resident doctors find it difficult to leave in the middle of a shift.  The resident doctors have raised this with the department and the resident doctors have been reminded of the importance of attending Foundation teaching and been assured it is protected time.  The practical difficulty of leaving during a busy shift still remains a concern with resident doctors.

The DME confirmed there is an expectation management in the department to release Foundation Years to teaching and it is regularly monitored.

An 8am handover meeting has been introduced to maximise work-based assessments (WBA) for resident doctors and a formalised afternoon post take ward round to maximise WBA.

TheSignal app is used to share the availability of interesting cases for bedside teaching, allowing for WBA and clinical procedures.

Self-Development Time is fixed into the rota for resident doctors.

GWH have addressed concerns around limited clerking opportunities for Foundation Years.  Proactive identification of clerking opportunities for foundation years has been implemented and identified daily.  An afternoon consultant ward round has been relaunched to ensure Foundation Year 1 patients are reviewed in person with the clerking doctor.

Domain 6: Developing a Sustainable Workforce 

The resident doctors have raised the 7-day rota as a concern with the department managers at GWH; it can be onerous working 7 days in a row, which includes 2 x 12-hour shifts.

The department are funded for 16.14 whole time equivalent (WTE) consultants in acute medicine.  The establishment at the time of the visit was of 8.4 vacancies, ie. ~50% recruited. Since the visit, the Trust updated us that one of the senior consultants is retiring in September, resulting in 9.74 WTE.

Two substantive consultants are expected to join in July.  The Trust are about to advertise for a substantive consultant and relist a specialist post, improving the department’s capacity to around 13.7 if successfully recruited.

Good practice

Recommendations

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