Executive summary

Resident doctors feedback around clinical supervision for General Internal Medicine (GIM) has improved compared to previous visits. Resident doctors and educators described an updated on-call support consultant model providing continuous 24 hours support across Queens Medical Centre (QMC) and Nottingham City Hospital (NCH). As this is a new system, resident doctors had no specific feedback or examples of its effectiveness, however it was broadly felt to be a positive step towards addressing previous supervision gaps. 

Resident doctors continued to highlight concerns regarding inequitable access to the acute take and Out of Hour (OOH) GIM provision and reported there was no oversight to ensure that there is a fair allocation of training opportunities for all specialties. They reported that the recent disbandment of the Chief Registrar role has left a gap in representation during meetings where changes in the rotas and roles and responsibilities are discussed. Although it was noted in the educator session that efforts are being made to improve this, educators confirmed there is still progress to be made to optimise the allocation of training opportunities. 

As previously reported, Acute Medicine are still accommodating a significant number of resident doctors, and this is placing a heavy burden on the consultants who are completing an overwhelming number of assessments to help resident doctors meet their outcomes.

Overall, some progress on clinical supervision was noted, however, oversight of this will be required to monitor its success.

Despite the efforts that the trust has made to resolve the issues with GIM training, the processes that have been put in place since previous visits have still not delivered the improvements required. As such, the Intensive Support Framework (ISF) category 2 rating for this concern will be maintained. The item will remain on the NHS England quality improvement register. 

Review overview

Who we met with

Learners

• Resident doctors in General Internal Medicine

Educators

• Clinical and Educational Supervisors in Acute and General Medicine

Senior team

• Director of Medical Education
• Deputy Director of Medicine Education
• College Tutor
• Postgraduate Quality Manager
• Divisional Head of Service
• Clinical Director for Emergency Services

Review panel

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

Background

A meeting with resident doctors and educators within Acute Medicine at Nottingham University Hospital NHS Trust (NUH) took place in December 2022 to explore in more detail the results from the 2022 General Medical Council (GMC) National Training Survey (NTS). Whilst feedback reported in relation to the overall training and education experience within Acute Medicine at Queens Medical Centre (QMC) was positive, issues were raised relating to the General Internal Medicine (GIM) rota, particularly the out of hours rota and especially at the City Hospital site.

A meeting took place with resident doctors on the GIM rota in February 2023. Following this meeting, potential patient safety concerns were raised in relation to the lack of clinical supervision within GIM and Stroke Medicine. Mandatory requirements were also put in place to improve training and education issues in GIM and to address the lack of the learning opportunities for procedures and limited clinic exposure. The trust submitted an immediate response to the patient safety concerns that provided assurances that they were already taking steps to address these issues at the time of our visit in February 2023. This was also supported by subsequent updated improvement plans.

Further learner educator visits took place in October 2023 and May 2024 to review the progress on the improvement plan. Improvements were noted in the clinical supervision for Stroke Medicine at these visits, however, despite the efforts that the trust has made to resolve the issues with GIM training and supervision, the processes that had been put in place had not delivered the required improvements.

Review findings

Clinical supervision out of hours

Overall, resident doctors reported improved clinical supervision for GIM compared to previous visits. They acknowledged and discussed long standing issues regarding the lack of a consultant on call acting as the senior decision maker for GIM. Resident doctors confirmed that there have been changes over recent months to OOH supervision and have all been advised of the newly implemented system of an on-call support consultant available 24 hours a day across QMC and NCH. As this is a new system in place, resident doctors had no specific feedback or examples of its effectiveness. They expressed uncertainty around the consultant’s awareness of their roles as on call support, and the extent of the decision making, and responsibility involved. While they still viewed this model as more of a support system rather than direct clinical supervision, they agreed it was a positive step towards addressing previous supervision gaps.  

During the educator session we also heard about the development of the on-call support consultant role which has been trialled since February 2024. With some improvements made to the escalation process, the on-call support role is now being rolled out. It was confirmed that communications have been sent to both resident doctors and the on-call support consultants and has received positive engagement. The educators reported that the new system has the support of the Medical Director, Divisional Director of Medicine and the Patient Safety Deputy Medical Director and it was felt by the educators that there is a determination to ensure the success of the new system. 

GIM provision

Resident doctors continued to highlight concerns regarding inequitable access to the acute take and OOH GIM provision across specialties. It was reported that the only way for them to obtain GIM experience is through the OOH rota. They described difficulties in being released from specialties to undertake GIM clinics. They also described the rota process lacking fairness or oversight, with shifts often going to those who get to ask first and choose shifts favourable for themselves. They reported there was no oversight to make sure that there is a fair allocation of training opportunities for all specialties. Additionally, resident doctors reported losing their continued professional development (CPD) time under the new rota structure leaving no provision to do clinics outside of their specialty. As a result, some resident doctors are using leave days to gain GIM experience.

Resident doctors expressed concern about the trust’s lack of understanding regarding GIM training requirements and felt there was insufficient consideration for some specialties. The recent disbandment of the Chief Registrar role was highlighted which has left a gap in representation during meetings to discuss processes relating to changes in the rota and roles and responsibilities. Additionally resident doctors reported that the college tutors are not included in these decisions causing a further disconnect with the training needs. Resident doctors reported that this is building tension amongst colleagues which negatively impacts the working environment.

Resident doctors were appreciative of the newly arranged forum for IMT2 resident doctors organised by the postgraduate medical education department (PMED). The group have met twice, and although some found this useful, not all resident doctors appeared to be aware of this.

During the educator session it was reported that that the GIM requirements for resident doctors’ is organised and managed by medical HR who provide a list of resident doctors assigned to Acute Medicine. Acute medicine consultants reported accommodating a significant number of additional resident doctors to help them meet their outcomes.

It was noted that recent efforts have been made to address these challenges including meetings between Medical HR, the Deputy Director of Medical Education and Hospital24 to discuss rostering to ensure that the rotas are balanced out the best way possible to improve equity across specialties. It is planned that the feedback from the resident doctor forum will feed into this meeting. It was acknowledged that there is still progress to be made to optimise the allocation of training opportunities.

In the educator session we also heard about NUH’s new organisational clinical model and leadership structure which the trust is working towards implementing in April 2025. The new model will move from six clinical divisions to four clinical care groups with changes to where directorates and services sit. It is hoped that this will potentially lead to the growth of general medicine.

Clinical supervision for GIM

In the educator session discussion took place around the absence of general medicine at NUH and the negative impact this has on education and training. It was recognised that Acute Medicine consultants are doing their very best to accommodate resident doctors for blocks to gain general medicine experience, however, this has placed a significant burden on the consultants. It was reported that consultants are completing an overwhelming number of assessments, examples of up to 60 assessments within 2 or 3 months which all felt raised a concern as to the quality of those assessments. Consultants also expressed concerns about completing Multiple Consultant Reports (MCR) for GIM despite having limited interactions with the resident doctors rather than working with them for an extended period as per the curriculum requirements.  

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Sarah Wheatley, Quality Deputy Manager
Review lead: Dr Syed Jafri, Training Programme Director
Date approved by review lead: 6 December 2024

NHS England authorised signature: Professor Jonthan Corne, Regional Postgraduate Dean
Date authorised: 16 December 2024

Final report submitted to organisation: 15 January 2025