Executive Summary

On 5 June 2025 WTE quality held face-to-face meetings with Princess Alexandra Hospital NHS Trust (PAHT) residents and trainers in Medicine posts to review the impact of the open improvement plan and evaluate progress following the 1 October 2024, multiprofessional engagement meetings which included residents from Anaesthetics, Emergency Medicine, Medicine, Paediatrics and Surgery. 

The report has been written in a manner to preserve the anonymity of residents and includes commendations for areas of good practice as well as educational requirements that will need to be addressed. NHS England Workforce, Training, and Education (WT&E) will work with the trust to review and update the open improvement plan to reflect the feedback from these meetings.

The meetings demonstrated many areas of good practice which include:

• Residents sense things are improving and feel there are good educational governance processes in place to support continuous improvement.
• Education is valued by the trust and the Medicine Division.
• The Medical Education Team and medical education centre were praised by all groups, with the team reported to deliver well run courses on site regularly.
• The referral pathways process to tertiary centres is much better than it was in October 2024. Additionally, the referral policy from A&E to other areas of the hospital was felt to be helpful.
• Residents are supported to attend training days, and there is regular GPST and PACES teaching.
• LEDs and SASs feel valued by the trust and find the medical education team supportive

PAHT is to be congratulated for the progress in many areas, noting change has taken place relatively quickly, at a time of significant financial constraint for the trust and the wider NHS. NHS England WT&E also wish to acknowledge and congratulate PAHT’s Director of Medical Education (DME), who received the Director of Medical Education of the Year award from Medical Education Leaders UK.

However, there are still concerns that need to be addressed, most of which are longstanding and identified as actions within the open improvement plan. We note that while improvement activities have commenced for many areas, further work is required to ensure improvements are embedded and sustained:

• Many Medicine FYs reported they did not feel supported on their first on-call shifts covering the wards and were worried about covering multiple wards which felt overwhelming and left no time for any breaks (including meal breaks).
• Medical staffing/rota coordination team was felt to be dismissive of leave requests and to not understand (or be sympathetic to) what residents need to achieve as learners. Both groups of residents found it difficult to access annual leave.
• While tertiary referrals are greatly improved, there is still work to be done to improve pathways for stroke patients as this was reported to not feel safe for patients.
• Many IMT residents still did not have exception report logins, and many FYs/GPSTs did not know the process for exception reporting.
• Both groups of residents felt Datix reporting takes too much time, and those who had reported felt feedback was not always provided.
• Staffing pressures prevent residents from attending clinics during their working hours and requires residents to come in on days off to achieve their curriculum requirements.

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 PAHT to agree milestones and actions against the educational requirements within the updated improvement plan.    

Review overview

Background to the review

The quality review meeting was initiated following ongoing concerns regarding the clinical learning environment within Medicine at Princess Alexandra Hospital NHS Trust (PAHT). The review meeting has been conducted in accordance with the NHS England WT&E Education Quality Framework Domains and Standards for Quality Reviews. PAHT has an active improvement plan in place and has been on the Education Quality Improvement Register since February 2020 for Medicine and the Medicine specialties. At the time of the meetings the Quality Improvement Register risk rating for Medicine was 20, Intensive Support Framework 3.  Since the concerns were identified, NHS England WT&E has held multiple interventions at several levels including senior leader engagements, regular stakeholder meetings, and multiple resident and educator engagement meetings, the most recent of which were the multiprofessional engagement meetings on 1^st October 2024, which included meetings with residents from Anaesthetics, Emergency Medicine, Medicine, Paediatrics and Surgery residents.  In October, the feedback from most programme groups was largely positive, so much so that the GMC removed the enhanced monitoring status following the meetings, however the Medicine programme was a low outlier, with Medicine residents citing significant challenges with workload and access to training. The purpose of this engagement was to triangulate the experiences of Medicine residents and hear directly about their perception of progress and the support provided to them following the October meetings.  

Evidence utilised:

• NHS England WT&E internal governance documentation which included feedback from meetings, improvement plan monitoring, and reports from previous engagement meetings.
• GMC National Training Survey 2024 and 2025 and National Education and Training Survey 2024 outcomes.

Who we met with

Learners

• 14 residents including FYs, IMTS, GPSTs, SHOs and STs from across the medicine subspecialties including Acute Medicine, Cardiology, Endocrinology/Diabetes, Gastroenterology, General Medicine, Geriatrics, and Respiratory
• 5 LED / SAS doctors from across medicine subspecialties

Educators

• 15 Educators/Consultants from across medicine subspecialties,

Education team

• Chief Executive Officer
• Director of Medical Education
• Interim Medical Director
• Medical Education Manager
• Divisional Director Urgent Care
• Foundation Training Programme Director
• Royal College Tutor for Medicine
• Freedom to Speak Up Guardian

Review panel

• Education Quality Review Lead – Marjorie Casey, Education Quality Manager,
• Speciality Experts – Dr James Edwards, Head of School of Medicine, Mr Shiva Dindyal, Deputy Foundation School Director, and Dr Jayne Hiley, General Practice Training Programme Director
• Education Quality Representative – Gemma Read, Education Quality Programme Manage

Review findings

The meetings were mostly well attended, (though higher residents’ attendance was an exception) with attendance from across the medicine subspecialties. In general, residents and trainers felt that Medicine at PAHT is on an improvement trajectory, though more still needs to be done.

Learning Environment and Culture

Residents and trainers reported a positive learning culture and praised the education centre facilities and medical education team for delivering well run courses on site regularly. The medical education team were reported to know most residents’ requirements and support them to attend necessary training.  LEDs and SASs also found the medical education team supportive. The Foundation Training Programme Director was also reported to be supportive, approachable and to organise meetings with foundation residents.

The culture for learning in clinical settings was more variable and dependent on the department and consultants, but most residents reported they are supported to attend training days, with GPSTs highlighting regular teaching is protected, and foundation residents reporting new PACES teaching has recently started and is very good.

Many residents have seen improvements, and reported they feel more supported and are better able to raise issues with registrars and consultants. Educators also noted improvements and, as an example, highlighted a new hybrid handover model which aims to improve both patient care and support to residents.  In handover staffing is reviewed with staff redeployed based on where the greatest needs are (if there are gaps in the rota). The hybrid meeting is led by the registrar on call, and the night team are provided lists based on the handover case reviews. Survey feedback indicates that residents feel more supported by the model which has enabled improved clarity, structures, and confidence.

FY1s are not scheduled on night shifts and felt this was supportive, but many did not feel supported for their first on-call shifts and reported concerns about covering up to 4 wards independently which can feel overwhelming and leaves no time for any breaks (including meal breaks) due to service demands (RQ1). They noted a registrar is on shift with them, but they are covering the other wards and are also very busy. Many FYs felt staffing covering the wards on weekends is not safe if there are any gaps due to illness, which is frequent. FYs felt they could escalate to registrars, who are supportive and responsive, but felt support from consultants was less accessible, with many unaware of who to contact, and that the consultant on-call list for weekends could be better communicated (RQ1).  

Residents reported the culture was largely positive, with most consultants and registrars felt to be supportive, and overall, good multiprofessional working within the department. There were no reports of bullying or undermining, though it was acknowledged the hospital is very busy and civility is sometimes strained when people are under pressure (RQ2). Many residents said they did not feel valued by the trust and felt particularly devalued by medical staffing/rota coordinators, who treat them as just a part of the rota; Medical staffing was reported by both groups of residents to be dismissive of individual requests, to not treat residents as professionals, and to not understand what residents need to achieve as learners, and both groups reporting difficulties accessing annual leave (RQ2, RQ3). However, it was noted that medical staffing come to the wards and try to be visible to work through issues. LED/SAS doctors did not have the same issues accessing annual leave.

Registrar grade residents and educators both reported significant improvements with referrals to tertiary hospitals, with registrars now able to speak to another clinician when needed, and able to escalate to their consultants if required. While tertiary referrals are greatly improved, it was acknowledged that there is still work to be done to improve pathways for stroke patients, with a current review in process to review stroke pathways (RQ3). Educators also noted there are concerns about cardiac cover at weekends and missed STEMIs, as some cardiology services are not available on the weekend (ECHO) which is challenging (RQ3).

Higher residents felt following the October 2024 Education Quality visit updated guidelines to support referrals from A&E had been very helpful, but felt this policy could be better communicated, as the policy was circulated, but many less senior residents were unaware of it and regular reminders needed to be provided to colleagues in A&E to follow the guidance. They felt it would be helpful to highlight the policy at induction meetings and to upload the policy to the intranet (and overall felt many guidelines on the intranet needed to be reviewed and updated) (RQ4, RC1).

Educational Governance and Commitment to Quality 

Many IMT residents did not have exception report logins (RQ4, RQ5). This was improved for FY1 residents, but many other FY2 or SHO doctors also did not have logins. Many FY/GPST/IMT residents did not know the process for exception reporting. While others, who had completed exception reports, noted some departments are not included in the drop-down lists, nor are some supervisors, and this had to be amended via free text. Higher residents did not feel they needed to exception report as they were mostly working within their hours (outside of clinics accessed in their own time). Educators noted there are fewer exception reports and felt this was due to the introduction of twilight shifts which support handover and leaving on time.

Both groups of residents reported the time required to complete Datix deterred them from reporting. Those who had reported felt feedback was not always provided, or was very generic, and did not address the specific incident (RQ5). Most residents knew the Guardian of Safe Working and Freedom to Speak Up Guardian, and felt if they had a patient safety concern, they knew the process for escalation and could access support from trusted consultants who they felt would act.

Residents noted there is evidence of good educational governance and gave positive feedback regarding the guidance for GI bleeds which was corrected after feedback was received that some doctors’ practice did not align with national guidance. The Resident Doctors Committee (RDC) was praised and felt to be effective in improving communication between residents, the hospital management, and education teams. The RDC is helpful in supporting a dialogue between medical departments and residents, with department representatives reported to listen and come back with feedback outlining how they could improve highlighted issues. Examples of issues addressed included greater clarity about physicians on-call and the distribution of a consultant out of hours list, and another example regarding training days and administrative days which are now incorporated in resident rotas, depending on sufficient staffing. Residents see things are improving, and felt educators/consultants take feedback seriously, though they noted the pace of improvements can sometimes be frustrating.

Developing and Supporting Learners

Foundation, GPST, and IMT residents noted they are frequently pulled off wards to cover other areas due to staffing shortages. They reported they had asked for clarification about the minimum staffing levels per area, but that these had not been clarified, or were not always met (RQ3).

Supervision out of hours was felt to be okay when staffing is sufficient, but if there are gaps SHOs feel very pressured at night covering 7-8 wards (RQ1). Residents perceived the rota teams often know when there are absences, but do not arrange locums to cover unless there were multiple days of absences. Locum cover was noted to be inconsistent across departments, with some departments more proactive in efforts to cover vacant shifts.

Medicine registrars reported access to clinics is difficult as many do not occur on site (RQ6) and the acute medical rota is given priority over clinics, though some areas are better able to support attendance (IMT clinics are arranged by service managers, and Respiratory bronchoscopy and pleural clinics were reported to be adequate). Accessing annual leave is challenging as medicine registrars can only take leave when they are scheduled on their ‘regular ward’ which can lead to missed learning opportunities in speciality areas (RQ6). Leave is not allowed when scheduled for twilight or on call shifts. Registrars feel they are required to ‘act down’ on twilight shifts, they felt the work is not particularly challenging and takes them away from clinics. They suggested if the Take was better organised the trust would not need as many doctors for twilight. Registrars noted educators are open to changing twilight shifts, but the rota has been formed until September, and nothing will be changed until then. To achieve necessary clinic requirements, many residents come in on days off (RQ6). Educators acknowledged the issue, and reported work is taking place to try to schedule clinics early in residents’ time with the trust to balance the needs between education and service requirements. Some educators felt it would be supportive to move away from tiers in Acute Medicine on the weekends, with input from subspecialties into the Acute rota (RC2).

Developing and Supporting Supervisors

Educators reported they feel supported by the trust and the trust values residents and educations. Educators receive the appropriate PA (0.25) per resident, but note clinical supervision, which is required by a wider group, is unpaid.

Educators report that staffing levels have improved, there are more doctors, and change is happening in a positive direction. The trust is working to increase educational supervisors with new recruits, and there is a feeling of renewed vigour to educate.

Delivering Curricula and Assessments

Many residents across levels felt they were only able to meet their curriculum requirements if they come in on their own time, i.e. outside of the rota, though educators report time in lieu is offered when requested (RQ6).  Most residents felt they received good support from educational and clinical supervisors to achieve their requirements, IMT regional teaching is supported, and foundation residents can meet core and non-core ARCP times. Some residents reported they struggled to get hub days approved, but this was resolved when escalated to their educational supervisors. Most departments were reported to be supportive of deanery teaching days.

Residents can access self-development/study days; though they are required to be on site and fill in if there are staffing shortages. If they are called in to fill a gap, they are allocated a make-up study day at another time. Both groups of residents reported significant issues accessing annual leave, even if requested well ahead of time (RQ3). Rotas are provided in good time, but many described annual leave requests for specific life events were rejected, even when there was time to work this out. They reported they felt required to organise swaps that then may not be approved. Medical staffing/rota coordinators were perceived to be frequently unhelpful with regards to annual leave requests (RQ2). Educators were reported to advocate for residents with medical staffing but noted there are challenges in filling vacancies (though business cases are being developed). The divisional director works with medical staffing and has been trying to make improvements.

Developing a Sustainable Workforce

Many residents would recommend their training post, though this would depend on the department; foundation level doctors would recommend the post due to team support, learning opportunities and the opportunities to be autonomous, with registrars recommending the post due to efforts the trust has made to make improvements.

Areas that are working well

Good practice

Areas for improvement

Mandatory requirements

Recommendations

Report approval

Report completed by: Marjorie Casey, Education Quality Manager
Review lead: Tracy Wray, Head of Education Quality
Date approved by review lead: 26 June 2025

NHS England authorised signature: Prof Bill Irish, Postgraduate Dean
Date authorised: 26 June 2025

Final report submitted to organisation: 18 July 2025