Executive summary
On 1 May 2025 face to face meetings were held with Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) residents and trainers in Medicine and Surgery posts (including higher, foundation, core and GP programmes) to review the impact of the open improvement plan and to evaluate the progress of improvements. NNUH has been under General Medical Council (GMC) enhanced monitoring since December 2022. The GMC added conditions to their approval of training at NNUH on 19 November 2024.
This report has been written in a manner that preserves the anonymity of residents and includes commendations for areas of good practice as well as educational requirements that need to be addressed. NHS England Workforce, Training, and Education (WT&E) quality will review and update the open improvement plan to reflect feedback from these meetings.
The meetings demonstrated areas of good practice which include:
- The trust is engaged with NHS England WT&E Education Quality processes, and all meetings were well organised and well attended.
- The rest and on-call facilities for residents were praised, particularly the improved doctor’s mess.
- Medical residents reported exception reports have been actioned, and they feel safer working nights due to increased staffing.
- Residents in most specialities reported being in a supportive clinical learning environment and said consultants were happy to teach them.
- When residents had experienced inappropriate behaviour, they felt their reports were taken seriously.
- Trainers reported feeling supported by the trust in their educator roles.
- The Resident Doctor’s Forum (RDF) is well organised and structured and focused on the residents.
However, there are still areas of concern that need to be addressed, some of which are longstanding and identified as actions within the previous improvement plan. This indicates a revised approach may be required to ensure improvements in these areas to ensure change is embedded and sustained.
- Concerns were raised by both residents and trainers in General Internal Medicine (GIM) that the centralised rota is not effective at supporting curriculum requirements across subspecialties.
- Some medicine residents reported they were not allocated a clinical supervisor, or their allocation was incorrect.
- Many medicine residents reported difficulties with using the switchboard to contact the on-call consultant. They reported the switchboard did not appear to have the on-call consultant rota.
- In some areas residents reported ongoing difficulties with the culture and inter-disciplinary working relationships, particularly in vascular surgery. Comments from residents included concerns with misogyny, racism and transphobia. Residents gave examples of nurses not enacting plans when given by a female or black residents, particularly on the vascular and colorectal wards. Some residents reported that they raised concerns about jokes and inappropriate comments regarding race, sexuality and gender identity, but did not feel action had been taken.
- Medicine residents reported that teaching was being impacted by vacancies, particularly for PACES training and the clinical fellow post in neurology.
- Not all foundation residents in medicine were aware of the Freedom to Speak Up Guardian or how to contact them.
- Patient safety concerns were raised regarding the onward referral of patients from the Emergency Department (ED) to other areas of the hospital in meetings with both medicine and surgery residents, with specific examples provided regarding referral of patients to Same Day Emergency Care (SDEC).
These areas need to be actioned and monitored against outcomes to ensure education quality improvements are embedded and sustained. NHS England WT&E will continue to work with NNUH to agree milestones and actions against the educational requirements within the updated improvement plan.
Review overview
Background to the review
The review meeting was instigated due to ongoing concerns regarding the clinical learning environment within medicine and surgery at the Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH). The review meeting has been conducted in accordance with the NHS England WT&E Educational Quality Framework Domains and Standards for Quality Reviews. The NNUH has an active improvement plan in place and has been on the NHS England WT&E Educational Quality Improvement Register since 2019, the current risk rating is 25 with an Intensive Support Framework rating of 3 and the trust has been in GMC enhanced monitoring since December 2022. NHS England WT&E have been monitoring the concerns and there have been multiple interventions at several levels including two senior leader engagements and five resident and educator engagement visits across varying programmes (the most recent of which were in March 2024 to encompass medicine and surgery and February 2025 for neurology residents). A programme of support for improvement is being implemented, including regular reviews of the trust improvement against the GMC and NHS England WT&E improvement plan requirements. The monitoring is ongoing and continuing through monthly assurance meetings with the General Medical Council (GMC), stakeholder partnership meetings in collaboration with the GMC and Norfolk and Waveney Integrated Care Board and partners. The purpose of this engagement meeting was to triangulate the experiences of medicine and surgery residents following ongoing concerns monitored by NHS England WT&E and the escalation of these concerns to the GMC in December 2022.
Who we met with
Learners
- 37 Core/Foundation/GP Residents (medicine)
- 23 Core/Foundation/GP Residents (surgery)
- 38 Higher Residents (medicine)
- 16 Higher Residents (surgery)
Educators
- 60 Educators (medicine)
- 37 Educators (surgery)
Review panel
- Regional Lead for Education Quality, Tracy Wray, Education Quality Review Lead (attended surgery)
- Education Quality Manager, Marjorie Casey, Education Quality Review Lead (medicine)
- IMT STC Chair – School of Postgraduate Medicine, Dr Anthony Griffiths, Specialty Expert (attended medicine)
- Associate Dean & Deputy Foundation School Director, Dr Francesca Crawley, Specialty Expert (attended medicine)
- Associate Postgraduate Dean for Quality, Dr Nisha Nathwani, Specialty Expert (attended medicine)
- ICM Training Programme Director, Dr Coralie Carle, Specialty Expert (attended medicine)
- Deputy Postgraduate Dean, Dr Helen Johnson, Specialty Expert (attended surgery)
- T&O Training Programme Director, Ms Lora Young, Specialty Expert (attended surgery)
- GP Training Programme Director, Dr Chathuri Hadinnapola, Specialty Expert (attended surgery)
- Education Quality Programme Manager, Sarah Folkard, NHS England WT&E Education Quality Representative (attended medicine)
- Education Quality Officer, Agnès Donoughue, NHS England WT&E Education Quality Representative (attended surgery)
- GMC Principal Education Quality Assurance Manager, Kevin Connor, GMC Representative (attended medicine)
- GMC Enhanced Associate, Professor Angie Doshani, GMC Representative (attended surgery)
Review findings
The meetings were well attended, allowing for a wide range of resident and trainer voices to be heard. In general, the residents and trainers we met with felt NNUH was on an improvement trajectory, but there was more still needed to be done. NHS England WT&E acknowledge the trust’s financial situation and their PFI status create additional challenges.
Domain 1 – learning environment and culture
In general, residents across both medical and surgical specialties were positive about the quality of training across their placements.
Residents in surgery reported an improvement in the culture. They said foundation residents were being encouraged to exception report, which they felt was a positive change. They reported feeling welcome and well supported in theatres. A resident in general surgery said they thought consultants were now more conscious of the need to be kind and supportive to residents. Residents in paediatric surgery said there had been a genuine shift in the culture and team dynamics had improved between different staff groups. Educators in trauma & orthopaedics reported they had introduced a consultant guardian, whose role was to flag up inappropriate comments and behaviour, and bystander training, which was working towards an improved culture. Residents in trauma & orthopaedics reported that consultants were supportive.
Residents in vascular surgery reported that issues with rudeness and incivility remained, with recent examples provided of residents being shouted at and asked to leave theatres (RQ1). Residents reported that there is now an anonymous form they can use to raise concerns, and senior management were taking complaints seriously. A resident said they had faith in the Medical Director’s leadership and were confident to raise concerns without fear of repercussions.
Some surgery residents reported that residents who were caucasian males were better respected than female or black residents. Medicine residents also reported the same. Examples were given of nurses not enacting plans when given by a female or black resident, particularly on the vascular and colorectal wards. Some residents reported that they raised concerns about jokes and inappropriate comments regarding race, sexuality and gender identity, but did not feel action had been taken.
Surgical residents raised concerns about onward referrals from ED regarding patient safety, with two specific examples of patients referred to SDEC from the ED without appropriate triage or intervention. These examples did not require a 5-day response but were shared with the trust’s senior leadership team immediately following the engagement meetings (RQ2).
In medicine, foundation residents across specialties highlighted supportive registrars and consultants, good team dynamics between different professional groups and a variety of learning opportunities.
We heard that residents felt included in the team and were encouraged to be independent. Foundation residents noted a good balance between suitable supervision and support to work independently.
Internal medicine residents reported an improvement in their experiences. IMT2 and IMT3 residents noted that current placements were more supportive and offered better learning opportunities than previous years. Several residents noted improvements in night shift support and staffing levels. Residents also reported being encouraged to take breaks and told to exception report if they went beyond their hours.
In GIM, residents reported access to outpatient clinics was improving but still limited, particularly during winter pressures. Access to procedures was described as better, though pleural procedures remained difficult to access.
Residents reported some incidents of bullying and undermining, particularly in the Acute Medical Unit (AMU), ED, and GIM. Residents felt this reflected individual behaviour rather than systemic issues. Residents also raised concerns about cultural expectations in some departments, including pressure to stay late and criticism during night shifts.
Residents in medicine were generally aware of exception reporting and the role of the Guardian of Safe Working (GOSW), but they were not all aware of the Freedom to Speak Up Guardian (FTSUG) or how to contact them (RC1). Some medicine residents reported their exception reports were rejected, with service pressures given as the explanation. Other residents felt exception reports did lead to improvements and safer staffing levels. Residents in surgery reported they were encouraged to exception report.
Residents in neurology reported they had been nervous about beginning their placements due to hearing about previous residents’ negative experiences, but it had been better than expected. This was attributed in part to improved minimum staffing levels. Residents in neurology also praised the weekly consultant-led teaching and opportunities to attend regional training. However, they raised concerns about the loss of a clinical fellow and the impact of this on their training opportunities, as not all residents were able to attend teaching sessions since the vacancy arose.
Residents were positive about the efforts to improve teaching opportunities. In emergency medicine, trainers reported there are two hours per day when residents can speak to consultants about their training. Dermatology residents praised their protected teaching sessions. In ophthalmology there was positive feedback for their weekly consultant-led sessions, a cataract simulation machine, and targeted MRCP support. Gastroenterology have introduced an endoscopy academy and are working to increase clinic access despite previous staffing challenges.
Residents and educators in medicine were positive about the previous PACES teaching programme and expressed concerns that it would not be reinstated following the retirement of the previous tutor. Residents described it as a significant loss and said it had been one of the best aspects of training at NNUH.
Residents in medicine reported they frequently had issues when using switchboard to contact an on-call consultant. They said the switchboard is not always aware of who is on-call and sometimes do not have their contact numbers. Residents described this as being stressful, especially during emergencies. They described it as happening roughly 30% of the time they called the switchboard. Residents said in these situations they must call the department director to get the correct on-call details. (RQ3).
Residents were positive about the improved doctor’s mess and reported that IT access is improving, but it can still be an issue. Residents also praised the on-call and rest facilities, although they did not like having to pay upfront for the on-call room and claim the money back.
Domain 2 – educational governance and commitment to quality
Residents were positive about the resident doctor’s forum. The observed session was well structured and well attended. There was a clear format with minutes and outcomes shared. The meeting was resident focused, and attendees were vocal.
Educators reported there is now divisional governance representation for education in governance and consultant business meetings. They said education is prioritised and documented. Both education and exception reporting are standing items on the divisional agenda to identify any areas of concern.
Domain 3 – supporting and empowering learners
Foundation residents in both medicine and surgery reported study leave could be difficult to get approved and only the more assertive residents would get it. They raised concerns that quieter residents would not be able to get their study leave approved. Some residents reported difficulties getting leave approved for mandatory training. Residents in respiratory medicine reported it was difficult to attend regional training due to the number of night shifts they complete. Residents also reported that lunchtime regional teaching is not protected and therefore difficult to attend. Residents reported it was difficult to contact medical staffing when needed, and that responses were slow (RQ4).
Some foundation residents in medicine reported they were either not allocated a clinical supervisor ahead of their placement, or that their assigned supervisor told them the allocation was incorrect. In these cases, the residents had to approach consultants to arrange their own supervisor (RQ5).
Domain 4 – developing and supporting educators
Educators reported they felt well supported by the trust and the postgraduate medical centre. They reported receiving regular updates about available opportunities for residents and educators.
Educators reported they receive the appropriate PA 0.25 per resident but note there are more and more individuals who require supervising including locally employed doctors (LEDs) and nurse practitioners, which is done in their own time.
Educators in both surgery and medicine expressed frustration about the triple lock on recruitment, including the policy on prioritising internal recruitment, which was causing delays in appointing vacancies. We heard concerns that this was impacting training for medical residents due to a vacant clinical fellow post in neurology and the lack of a replacement for the previous PACES tutor (RC2). Educators also acknowledged there are restrictions on physically expanding training provision due to the trust’s PFI status.
Domain 5 – delivery curricula and assessments
Medicine residents and educators reported concerns with the GIM centralised rota, stating it does not support residents to meet the needs of their curriculum, which will differ across the specialties. Medicine educators expressed a desire to have more involvement in the GIM rota planning and to have representatives from each specialty to advocate for the needs of their residents. They also reported that a training programme director for GIM could be a useful addition to support with an appropriate rota (RC3).
Medical residents reported that access to clinics was inconsistent across specialties. Internal medicine residents reported they did not get enough opportunities to take part in clinics, as they are not currently part of the rota. We heard that clinics will be part of the internal medicine rota from August. Cardiology residents reported having frequent access to clinics, however those in acute medicine said they never get to go due to service pressures. Both dermatology and cardiology residents stated that access to procedures is very competitive and there is a long waiting list.
Surgery residents also reported a mixed experience. Orthopaedics residents reported they did not get to attend clinics often as there are not enough registrars. They reported that residents are not meeting requirements for elective clinics, although most residents are meeting requirements for theatres. Residents in paediatric and general surgery reported having good access to clinics. One resident in vascular surgery reported only attending one clinic between October and March, due to rota gaps and workload (RQ6).
Educators in the medicine meeting were positive about an increased focus on quality improvement projects for residents. We heard that a session on Quality Improvement is held during induction, and educators support residents to help them find or create QI projects. Educators reported residents have presented their projects in a variety of forums.
Domain 6 – developing a sustainable workforce
Approximately two thirds of foundation residents in medicine said they would recommend their current placement, and the majority said they would recommend the training programme in general. Approximately half of higher residents in medicine said they would apply for a job. One higher resident reported they had been advised by a consultant not to apply for a job at NNUH.
There was a mixed response from foundation and higher residents in surgery. Reasons for not recommending the placement or applying for a job focused on concerns with the rota and with workload.
Areas that are working well
| Description | Domain(s) and standard(s) |
|---|---|
| Work ongoing to improve triage for frailty and criteria for accepting patients in neurology, in response to previous engagement meeting requirements. Also increased minimum staffing levels with medicine residents in neurology reporting they feel safer. | 1.5 |
Good practice
| Description | Domain(s) and standard(s) |
|---|---|
| Residents reported being encouraged to exception report when they missed breaks or worked additional hours. We heard the trust acted upon exception reports and residents felt this had led to improvements such as safer staffing at night. | 1.5, 1.6. |
| Resident and foundation residents across most medicine and surgery subspecialties praised an improvement in the culture and reported feeling well supported. Reporting systems are in place for residents to raise concerns about inappropriate behaviour. Educators in some areas have undertaken additional training such as bystander training. The trust is sharing the learning from areas where improvements have been made. | 1.3, 1.6 |
| Trainers reported improved governance structures, with education and exception reports added as standing items to divisional agendas. In addition, the resident doctor’s forum was well structured and well attended with vocal participation from trainees. | 2.4, 2.7 |
| Educators in both surgery and medicine meetings reported that they felt well supported by the trust in their training roles. We heard the trust’s senior leadership values education. Educators reported they received 0.25 PA per trainee. | 4.2 |
| Foundation and higher residents across medicine and surgery subspecialties praised the variety of training opportunities available, including consultant led-teaching, simulation sessions and regional teaching. IMT2 and IMT3 residents reported a significant improvement in their learning opportunities compared to their previous experience. | 5.1 |
Areas for improvement
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| Residents in both medicine and surgery reported that issues remain with rudeness and incivility in some areas. Residents reported concerns that Caucasian male residents shown more respect than black and/or female residents by some staff, including nurses, and there were issues with clinical staff refusing to follow plans given by resident doctors. | NHS England WT&E require assurance that: • there is appropriate workplace training to support team dynamics and civility. • there are processes for residents to raise concerns relating to equality, diversity and inclusion, with clear pathways for feedback and actions. • wellbeing support is available for residents, and they are aware of how to access this. | RQ1 Education Quality Framework Domain: 1.3, 1.6, 1.7, 1.8 |
| Residents in both medicine and surgery raised patient safety concerns regarding onward referrals of patients from ED to other areas of the hospital, without appropriate triage or intervention. | NHS England WT&E require assurance that a system is in place for onward referral of critically ill patients, including appropriate and timely consultant input. | RQ2 Education Quality Framework Domain: 1.5 |
| Foundation residents in medicine reported difficulties contacting on-call doctors due to the switchboard not having the necessary information, both in terms of who was on call and their contact information. | NHS England WT&E require assurance that systems are put in place to ensure that the switchboard has the appropriate information for on-call provision. | RQ3 Education Quality Framework Domain: 1.5, 1.6 |
| Residents in both medicine and surgery reported difficulties in getting study leave approved, including for mandatory training. | NHS England WT&E require assurance that: • there is a fair allocation process for study leave, which allows all residents to meet their curriculum requirements. • that residents are released to attend mandatory training sessions. | RQ4 Education Quality Framework Domain: 3.2 |
| Some foundation residents in medicine reported they were not allocated a clinical supervisor, or that their allocated clinical supervisor told them it was incorrect. | NHS England WT&E require assurance that all residents are assigned a clinical and educational supervisor in advance of their placements. | RQ5 Education Quality Framework Domain: 3.4, 3.5 |
| Residents in both medicine and surgery reported issues in getting exposure to clinics and different procedures needed to meet their curriculum requirements. | NHS England WT&E require assurance that: • in medicine, representatives from each subspecialty are involved in rota planning, to ensure that the rota allows for residents to meet their curriculum requirements. • that in both medicine and surgery, residents are allocated time in clinics as part of their rotas. | RQ6 Education Quality Framework Domain: 3.6 |
Recommendations
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
| NHS England WT&E quality recommend that the trust reviews their induction programme and ensures that details about the FTSUG and how to contact them are clearly communicated. | RC1 Education Quality Framework Domain: 1.7 |
| RC2: NHS England WT&E quality recommend that the trust reviews the clinical fellow vacancy in neurology and the PACES tutor vacancy in medicine, to ensure continuity of learning opportunities for residents. | RC2 Education Quality Framework Domain: 3.6 |
| RC3: NHS England WT&E quality recommend that the trust recruits a training programme director for GIM, which would further support RQ6. | RC3 Education Quality Framework Domain: 2.1 |
Report approval
Report completed by: Sarah Folkard, Education Quality Programme Manager
Review lead: Tracy Wray, Regional Lead for Education Quality
Date approved by review lead: 23 June 2025
NHS England authorised signature: Professor Bill Irish, Regional Postgraduate Dean
Date authorised: 23 June 2025
Final report submitted to organisation: 7 July 2025