Executive summary
On 6 December 2024 (higher residents), 3 February 2025 (GP and Foundation residents), and 5 February 2025 (Midwifery learners), virtual resident and educator review meetings were held with JPUH midwifery and Obstetrics & Gynaecology (O&G) residents and educators to seek an updated understanding of education and training from the student and educator perspective. This report has been written in a form which preserves the anonymity of residents, learners, and educators. The report includes commendations for areas of good practice as well as educational requirements that need addressing through an improvement plan.
The meetings evidenced that midwifery had seen improvements since the 26th of July 2023 engagement meetings, which aligns with evidence provided in trust improvement plan submissions. However, some concerns remain for higher O&G residents and GP and Foundation O&G residents also reported multiple areas of concern.
The meetings demonstrated many areas of good practice which included:
Midwifery
Improvements against areas of concern identified at the July 2023 engagement meeting:
- The Safety Huddle was praised by learners who felt well
- Learners cited access to MDT training as
- Learners fed back that the trust’s Educator Midwife is key in continuing to drive positive change and described the support provided as “fantastic”.
O&G
- All resident doctor groups felt confidence in the consultant’s ability to support clinical escalations – residents felt that in instances where clinical opinion differed between staff, this is managed well, and resolutions are achieved.
- GP and Foundation residents felt that higher residents were keen to teach and this was welcomed.
There were areas identified that require further improvement in O&G: GP and Foundation
- Concerns that patients in the Early Pregnancy Assessment Unit (EPAU) are not always managed appropriately.
- EPAU specific induction is not provided.
- Supervision is not always robust – residents felt they were expected to manage the patient caseload themselves.
- Lack of resilience in staffing at times of sickness with financial pressures felt to be a reason the trust did not use locums.
- Residents felt unable to take study leave
- Teaching was reported to be variable and did not always take place
NHS England Workforce, Training, and Education (WT&E) quality will continue to work collaboratively with JPUH and develop actions to support with sustained improvements.
Review overview
Background to the review
The review was initiated following ongoing monitoring of concerns within the maternity learning environment, from a previous NHS England WT&E engagement meeting with trust obstetrics and gynaecology (O&G) residents and midwifery learners in July 2023. At the time of the engagements associated with this report, James Paget University Hospitals (JPUH) NHS Foundation Trust’s O&G and midwifery programmes were included on the National Education Quality Improvement Register with a risk rating of 16 and an Intensive Support Framework Score of 2.
The aim of these engagement meetings was to listen to the experiences of midwifery learners/educators and O&G resident doctors/trainers and understand progress against areas of required improvement. The review meeting was conducted in accordance with the NHS England Education Quality Framework Domains and Standards for Quality Reviews for education and training.
Who we met with
Learners/Resident Doctors
- 6 midwifery learners
- 3 higher O&G residents (out of a cohort of 4)
- 4 GP and Foundation residents Educators
- 3 midwifery educators
- 4 O&G trainers
Senior trust team (high-level feedback to trust)
- Associate Director for Maternity Improvement
- Chief Executive Officer
- Director of Medical Education
- Medical Director
Evidence utilised
- NHS England internal governance
- GMC National Training Survey 2023, National Education and Training Survey (NETS) 2023, and embargoed NETS 2024 outcomes.
- CQC report published May 31st,
- In December 2024, concerns for maternity patients at the trust were identified including a near miss; there were concerns that O&G residents lacked clinical confidence in consultants at JPUH.
Review panel
Education Quality Review Lead:
- Ryan Collins, Education Quality Intelligence Analyst Specialty Experts:
- Erika Manzo (Head of School for O&G)
- Dr Helen Barker (Foundation School Director)
- Debbie Cubitt (Senior Clinical Manager, East of England)
- Mandy Kerr (Senior Clinical Lead, East of England) NHS England WT&E Education Quality Representatives:
- Helen Johnson (Patch Dean for N&W ICB)
- Agnès Donoughue (Education Quality Coordinator)
- Hayley Peacock (Education Quality Officer)
Review findings
Domain 1 – Learning Environment and Culture
Midwifery
Midwifery learners reported significant improvements to the learning environment, culture, and staffing, underpinned by strong support from the whole maternity team, trust senior team, and multiprofessional colleagues. Although learners felt a minority of midwives were less enthusiastic about managing learners than others, overall, the feedback was positive for the learning environment. High service pressures at times were challenging, but learners felt well supported by educators in these instances.
Midwifery learners were supported in achieving learning outcomes through twice-daily student hubs and were allocated supervisors appropriately. This aligned with educators citing multiple support mechanisms and initiatives for learners including safety huddles, a bereavement study day to support learners in achieving efficiencies, ongoing collection and response to learner feedback, a new preceptorship programme, and tailored interview preparation/support.
Despite feeling supported by the trust in seeking employment post qualification, midwifery learners were anxious about securing employment and maintaining their skills should there be a delay between qualification and employment (RC1).
O&G
O&G resident doctors felt rota arrangements were appropriate and emphasised the trust actively listened to resident feedback and cited examples where the trust continues to implement improvements. Staff were perceived to take interest in residents’ learning goals and weekly clinics were rostered. Foundation/GP and most higher resident doctors did not have cultural concerns; we heard that one higher resident escalated a cultural concern which was effectively resolved. Foundation and GP O&G residents stated higher residents were keen to teach and develop them.
We heard reports from Foundation/GP O&G residents that early pregnancy patients, being managed through the Early Pregnancy Assessment Clinic, were not always reviewed appropriately and did not always receive appropriate care. Residents perceived this was attributable to unstructured chaperone arrangements, unstructured access to diagnostics, insufficient resident supervision, and lack of access to facilities to meet patient needs (resulting in delays to patient care). Whilst residents were aware they could escalate to the on-call consultant, they were unable to identify the named consultant responsible for the overarching management of the Early Pregnancy Assessment Clinic (RQ1). We also heard that Foundation/GP O&G residents did not receive an induction to EPAU (RQ2).
Domain 2 – educational governance and learnership
Midwifery learners felt that there were appropriate systems for raising concerns about education and training, were familiar with escalation processes for exception/Datix reporting and were confident escalating – but there is some scope for improvement in communicating escalation steps and outcomes (RQ3). Not all midwifery learners were familiar with the Freedom to Speak Up Guardian process, but confident educators would signpost them appropriately if needed (RC2). We heard that practice educator assessor staffing was sufficient to enable 1:1s for learners and link lecturer presence was appropriate.
Midwifery educators outlined processes in place to inform stakeholders and support learners with patient safety issues and performance challenges. All learners and residents felt there was strong and improved support from trust leadership for education and training.
Most GP and Foundation residents were not confident in exception reporting processes and therefore were not exception reporting as routine (RC3).
Domain 3 – developing and supporting learners
Midwifery
Midwifery learners noted that supernumerary status was challenging to maintain at times of high service pressure but felt well supported by educators in this area; educators emphasised learner wellbeing and outlined mitigations for protecting supernumerary status during times of short staffing. Although learners felt positively about induction, midwifery educators reported learner inductions sometimes took place virtually due to a lack of room availability. Learners praised the Clinical Educator Midwife for their role in driving positive change.
O&G
Higher O&G residents shared they had confidence in consultants’ ability to support clinical escalations and, in instances where clinical opinions differed between staff, this was now managed well with appropriate resolution achieved. Higher residents reported if they lacked confidence in the advice provided, they would feel confident providing challenge. Higher O&G residents thought obstetric acuity was sufficient to achieve their curriculum requirements and access to learning opportunities was good; although access to complex procedures was felt to be limited and access to theatres could be improved. The elective c-section lists were recently changed to ensure registrars are in attendance under consultant supervision. Higher residents felt the rota was fit for purpose with no significant gaps.
GP and Foundation residents felt that staffing challenges resulted in significant pressures, with residents covering 3 areas in addition to A&E; the rota was thought to have scope for improvement in facilitating attendance at planned education sessions and the ability to access study leave; some GP and Foundation residents at times struggled to identify rota swaps to enable leave, and sickness absence had resulted in missed outpatient clinics (RQ4). GP and Foundation residents understood who they could contact for support but felt that the trust no longer rostered locums due to financial constraints.
All residents we met with felt immediate consultant support was available when required and raised no concerns about having to work outside their scope of practice. Higher O&G residents felt that education quality was on a positive trajectory underpinned by strong resident feedback loops. They felt supervision arrangements were effective, but residents would welcome additional meetings with supervisors and weekly CTG meetings often clashed with planned teaching sessions (RC4, RC5). GP and Foundation residents, however, thought supervision was inadequate for them (RQ5).
Following the recent decant of ward 11 to ward 7 for maternity activity, some doctors indicated they were unable to easily locate equipment with challenges finding swabs particularly noted (RC6).
Domain 4 – developing and supporting educators
Midwifery educators felt valued by their department. Since 2024, a supernumerary Band 6 midwife has been in post to support learners’ transition to preceptors, but this seconded role was coming to an end (RC7). Challenges around expansion pressures when the department was at capacity for midwifery learners and limited room booking availability for staff training were noted.
O&G trainers felt well supported by the trust and had appropriate access to room bookings; additional consultants would be welcomed to improve the balance between training and service for residents. O&G trainers outlined the support mechanisms in place for trainers under scrutiny following clinical complications including a buddy system. The psychological safety of trainers subject to scrutiny was flagged as a significant concern, including the impact of incident report harm level calculations prior to full internal reviews taking place (RQ6).
Domain 5 – delivering curricula and assessments
Four of the 6 midwifery learners we met with would recommend the trust to a friend for training. The key factor discouraging learners from recommending were anxieties around achieving the 40 spontaneous births curriculum requirement, as the trust was perceived as having a high c- section rate. Another learner would prefer to work in a larger trust due to increased staffing resilience.
GP and Foundation O&G residents felt that they had progressed during their placement due to exposure to service provision, but progress attributable to formal teaching was seen as limited; we heard that departmental teaching is sometimes cancelled, and residents are not always notified.
Areas that are working well
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
| Significant improvement against areas of concern identified at the July 2023 engagement meeting including clinical supervision, culture, trust leadership from an education and training perspective, confidence escalating concerns, link lecturer presence. | 1.1, 1.7, 2.1, 3.5 |
Good practice
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
| Midwifery learners highlighted that the trust’s Clinical Educator Midwife was instrumental in continuing to drive positive change and described the support provided by this colleague as “fantastic”. | 1.1 |
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| Concerns regarding early pregnancy patients not being managed through EPAU, heightened by lack of clear chaperone processes and limited access to diagnostics. Challenges identifying named on-call consultant for EPAU. | NHS England are seeking assurance that: There are governance structures for management of patients in EPAU which are communicated to all staff, including the process for escalating concerns to the on-call consultant. There is a clear process for chaperone arrangements, which is communicated to all staff. Appropriate clinical supervision is available for learners working within EPAU. | RQ1 Education Quality Framework Domain: 1.5, 1.6 |
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| Foundation/GP O&G residents reported that they did not receive an induction to EPAU. | NHS England are seeking assurance that: O&G trainees receive an appropriate induction to EPAU. The trust is to seek feedback on revised EPAU induction processes and share with NHS England WT&E. | RQ2 Education Quality Framework Domain: 3.9 |
| Midwifery learners reported that there were appropriate systems for raising concerns about education and training, and that they were confident with Datix/exception reporting processes, but that there was scope for improvement in receiving feedback on escalations and outcomes. | NHS England are seeking assurance that: Escalation steps and outcomes are communicated to learners within a reasonable timeframe. | RQ3 Education Quality Framework Doman: 1.7 |
| GP and Foundation residents reported challenges due to rota gaps, with residents covering 3 areas in addition to A&E. They reported that it was a challenge to attend education and training sessions and that outpatient clinics had been missed due to service pressures. They reported that they were not confident with the exception reporting process. | NHS England are seeking assurance that: All residents’ workloads and rotas facilitate and support attendance at planned education sessions, and that attendance is shared with NHS England for assurance purposes. The trust ensures that communications to residents emphasise the importance of attending planned education sessions The process for exception reporting is clearly communicated to residents and residents are encouraged to make reports when appropriate. | RQ4 Education Quality Framework Domain: 3.6, 3.7 |
| GP and Foundation residents reported that supervision was inadequate. | NHS England request the trust to take the following actions: Share the outcomes of a resident doctor to trainer audit. Provide assurance that processes and governance for Foundation and GP residents are supported by appropriately qualified staff. Collate and respond to Foundation/GP resident feedback pertaining to supervision quality. | RQ5 Education Quality Framework Domain: 3.4, 3.5, 3.6 |
| O&G trainers outlined the support mechanisms in place for trainers under scrutiny following clinical complications including a buddy system. The psychological safety of trainers subject to scrutiny was flagged as a significant concern, including the impact of incident report harm level calculations prior to full internal reviews taking place. | NHS England are seeking assurance that: O&G trainers subject to scrutiny following significant events are appropriately supported through the process. | RQ6 Education Quality Framework Domain: 4.1 |
Recommendations
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
| To provide support to alleviate midwifery learner anxieties about maintaining their skills post qualification and pre-employment: NHS England WT&E recommends that the trust signposts learners to support for maintaining skills during the gap between qualification and employment. | RC1 Education Quality Framework Domain: 6.1, 6.4 |
| To ensure midwifery learners can directly access the Freedom to Speak up Guardian should they need to: NHS England WT&E recommends that the trust signposts learners to their local Freedom to Speak up Guardian. | RC2 Education Quality Framework Domain: 1.7 |
| To ensure O&G residents are familiar with exception reporting processes, and supported to complete exception reports as required: NHS England WT&E recommends the trust review reporting processes and seek assurance that all residents have been set up to exception report and are familiar with associated processes and ensure residents are enabled and supported to exception report when required. | RC3 Education Quality Framework Domain: 1.4, 1.5, 1.7 |
| To further improve the educational experience of higher O&G residents: NHS England WT&E recommends that the trust review the possibility of providing higher O&G residents with additional supportive meetings with supervisors if requested. | RC4 Education Quality Framework Domain: 3.5, 3.6 |
| To further improve the educational experience of higher O&G residents: NHS England WT&E recommends that the trust review the possibility of protecting time for weekly CTG meetings which reportedly often clashed with planned teaching sessions. | RC5 Education Quality Framework Domain: 3.6 |
| To provide assurance that O&G residents are familiar with equipment locations following the move to ward 7: NHS England WT&E recommends that the trust reviews the location of key equipment on ward 7 and ensures that they are made clear to O&G residents. | RC6 Education Quality Framework Domain: 1.5, 1.6 |
| To ensure that improvements to midwifery education continue to be embedded: NHS England recommend that the trust continue to take steps to increase the funded education hours of the Clinical Educator Midwife, with a view to achieve full-time equivalent funding. NHS England recommend that the trust have appropriate succession planning in place for the Clinical Educator Midwife post. NHS England recommend that the trust confirms appropriate support is in place for learners following the end of the supernumerary Band 6 midwife’s secondment. | RC7 Education Quality Framework Domain: 3.6 |
Report approval
Report completed by: Ryan Collins
Review lead: Tracy Wray
Date approved by review lead: 23 July 2025
NHS England authorised signature: Prof Bill Irish, Regional Postgraduate/Multiprofessional Dean
Date authorised: 24 July 2025
Final report submitted to organisation: 15 August 2025