Executive summary

The results for the 2023 General Medical Council (GMC) National Training Survey (NTS) showed multiple categories where responses were below the national average at Northampton General Hospital NHS Trust (NGH), for postgraduate doctors in training (PGDiT) within Medicine. To better understand their experience of the clinical learning environment, a learner educator meeting was arranged for June 2024.

Overall Internal Medicine Stage 1 (IMS1) and Internal Medicine Stage 2 (IMS2) PGDiT described differing experiences with their education and training at NGH.  Whilst both groups described a supportive environment, it was only the IMS2 PGDiT that recommended Northampton General Hospital NHS Trust (NGH) as a place to train or as a place to receive treatment.

All PGDiT were comfortable with raising concerns, however, the IMS1 PGDiT felt that there was a lack of response to raising concerns. They also felt there was little point in exception reporting as it was their perception that these are not acted upon, and it was reported that some PGDiT do not have access to exception reporting. 

There was positive feedback from IMS2 PGDiT in terms of clinical and educational supervision, learning opportunities and recognition of training needs. They described their teaching as good and had no issues with completing assessments. 

Both groups reported challenges with the coordination of the rota including a lack of support and understanding of training needs and difficulties with booking any type of leave including study leave for compulsory examinations, even if giving six weeks’ notice. They reported regularly having to swap on calls to go to teaching as regional and local teaching are not timetabled into their rota. However, we did hear from educators that there are plans in place to address some of these concerns and they were confident of improvements being made to the rota in August 2024.

There were also challenges reported by the IMS1 PGDiT regarding a lack of learning opportunities in Acute Medicine due to rotations based in specialities such as Haematology, Palliative Care and the Intensive Therapy Unit (ITU) therefore not allowing adequate exposure to deliver the Acute Medicine experience required. The PGDiT expressed concern about being expected to manage the acute take as an IMT3 having had very minimal experience. In addition, some IMS1 PGDiT described challenges with access to clinics. They reported working on days off to fulfil the Acute Medicine assessments and clinic requirements.  

In the educator session it was clear that all educators were committed to training, and we recognised the significant amount of work that the education leads are putting in to improve the training and education experience.

To summarise the areas to be addressed by the trust are as follows:

• Rota
• Learning opportunities
• Exception reporting
• Raising concerns
• IT access

To ensure that improvements are sustained, the Intensive Support Framework Category (ISF) 1 rating for this concern will be maintained and this item will remain under local monitoring. A Trust Improvement Plan will be required against the mandatory requirements outlined in this report. 

Review overview  

Who we met with

Learners

• Internal Medicine Stage 1 (IMS1)
• Internal Medicine Stage 2 (IMS2)

Educators

• Clinical and Educational Supervisors in Acute Medicine, Cardiology and Respiratory
• Clinical Tutor

Senior team

• Director Medical Education
• Medical Education Manager

Review panel

• Dr Bisharat El-Khoury, Head of School for Medicine
• Dr Syed Jafri, Training Programme Director
• Dr Winston Rennie, Training Programme Director, Foundation
• Sarah Wheatley, Quality Deputy Manager

Review findings

Learning environment and culture

IMS1 PGDiT described the support provided to them as generally good and described the College Tutor and Training Programme Directors as very supportive. They were all comfortable with raising concerns, however, felt that there is sometimes a lack of response to concerns raised. IMS1 PGDiT described a functioning Junior Doctor Forum (JDF) where minutes are taken, and actions are logged. All IMS1 PGDiT were aware of how to exception report, however, perceived that these are not acted upon, so it was felt there was little point to exception reporting. They also felt that some educational supervisors were unaware of the exception reporting processes and there were reports of some PGDiT not having log in details. 

IMS1 PGDiT described the working environment and facilities as good overall, highlighting the on-call room and parking facilities as positives. During the induction period, there were reports of delays to log in access to computer systems in Acute Medicine and delays with obtaining parking permits. They described feeling overwhelmed by the information provided at induction, as their department inductions for two different specialties took place on the same day.  

IMS2 PGDiT in Dermatology, Gastroenterology, Respiratory, Cardiology and Geriatric Medicine described a supportive working environment and spoke positively about their training experience, reporting good opportunities, good supervision, and a recognition of training needs. They felt well supported by their clinical and educational supervisors who they described as just a phone call away. All were comfortable with raising concerns and felt these were acted upon.  None of the IMS2 PGDiT had needed to exception report. 

All IMS2 PGDiT said they would recommend their training posts and recommend NGH as a place to receive treatment. However, the majority of IMS1 PGDiT would not recommend their training post, mainly due to issues with the rota and would also not recommend NGH as a place to receive treatment. 

Rota coordination

IMS1 PGDiT reported that their main concern was around the coordination of the general medicine rota. IMS1 PGDiT felt there was a general lack of support and understanding of training requirements from rota coordinators and reported difficulties with booking any type of leave, self-development time (SDT) and clinics. They also felt it would have been useful to clarify how the rotas work for general medicine and specialities during induction and who they should report absences to. IMS1 PGDiT described difficulties with getting study leave for compulsory exams such as Practical Assessment of Clinical Examination Skills (PACES) and are instructed to find their own swaps to free themselves up which is difficult. There were examples of some PGDiT having to sit exams whilst rostered for a night shift because they could not find swaps.  They also described difficulties with getting any time for exam preparation.  

IMS2 PGDiT also described challenges with the rota including having been given a 4-month schedule when they are on a 6 or 12-month rotation. They described delays with study leave approvals, issues with getting study leave for mandatory teaching, and are regularly swapping on calls to go to regular teaching. They all felt that teaching should be incorporated into the rota rather than having to apply for study leave for all teaching sessions and compared this process unfavourably to other trusts. They also reported being continually told by rota coordinators that leave would not be allowed due to insufficient junior staff on the ward, even though registrars roles do not count as minimum numbers required. They reported that these issues often remain unresolved until consultants’ step in to support them, which causes frustrations with PGDiT.  

In the educator session we heard that the issues with the rota had been identified and there were plans in place to address these concerns including offering rotas for 12 months rather than 4 months and including SDT time on the rota. They also described a plan in place to work with the rota coordinators to outline expectations of how this is to be implemented. Educators were confident that these changes would make improvements to the rota from August 2024. 

Developing and supporting learners

IMS1 year 2 PGDiT reported a lack of Acute Medicine experience due to several rotations not including Acute Medicine. For example, some PGDiT only had 7 days in Acute Medicine over the course of a year, making it difficult to complete Multiple Consultant Reports (MCRs). They expressed concern about progressing to IMT year 3 and being expected to manage the acute take with minimal experience. Additionally, they described difficulties with getting Acute Care Assessment Tool (ACATs) completed and reported working on days off to fulfil the Acute Medicine assessment requirements. Although they acknowledged that there had been some improvement compared to last year, it was felt there are still inadequate Acute Medicine opportunities. 

IMS1 PGDiT also reported a lack of clinic time on some rotations with clinic time only being undertaken in same day emergency care (SDEC). They reported going in on days off to get more clinic experience. There were reports of difficulties with getting Direct Observation of Procedural Skills (DOPS) signed off with examples of only getting these completed 2-3 days prior to ARCP. There was a perception that rota coordinators are unaware of the importance of attending clinics and it was felt that they do not understand training requirements.  

IMS2 PGDiT reported that HST teaching takes place every week with a good mixture of specialty topics and described the teaching as very good. Overall IMS2 PGDiT spoke positively about their learning opportunities and had no issues with getting assessments signed off. Some IMT2 PGDiT did raise difficulties with the processes for booking time for clinics which they found cumbersome and reported some issues with rota coordinators constantly rejecting requests for clinics. They all felt that preset clinic days should be incorporated into the rota. 

In the educator session it was clear that all educators were committed to training, and we recognised the significant amount of work that the education leads are putting in to improve the training and education experience. Although time in job plans is allocated, there are a limited number of supervisors, and some barriers were reported in meeting with their supervisees. It was also felt that there is a lack of structure in supporting educational supervisors for the role.  To assist with this, the educators discussed developing an educational faculty. We also heard about many education sessions including procedural skills, simulation training for human factors, train the trainer teaching and a PACES programme. There are also plans to recruit more College Tutors to support with educational activities. 

Requirements

Requirements are set where NHS England have found that standards are not being met; a requirement is an action that is compulsory. These are categorised between Mandatory Requirements that NHS England will require an update against as part of the collective findings and Immediate Mandatory Requirements that given the severity, will require an urgent response.

Mandatory requirements

Report approval

Report completed by: Sarah Wheatley, Quality Deputy Manager
Review lead: Bisharat El-Khoury, Head of School for Medicine
Date approved by review lead: 28 June 2024

NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean, Midlands
Date authorised: 10 July 2024

Final report submitted to organisation: 31 July 2024