Executive summary

The NHS England review panel thanked the Trust for accommodating this quality review and for facilitating good attendance on the day. After discussions with the Trust’s educational leadership team, it was clear to the panel that the Trust were aware of the issues affecting a number of medical specialties across the site and that they had devised plans to improve the training experience of resident doctors placed within medical specialties at North Middlesex University Hospital.

It was also positive to hear that resident doctors were involved in developing some of the solutions. It was noted that the Trust valued internal medicine training resident doctors and their contributions within the different medical specialties to drive improvement.

The panel assigned provisional Intensive Support Framework (ISF) ratings for the programmes as following:

• Acute Internal Medicine: ISF 2 (unchanged)
• Internal Medicine Training Stage One: ISF 2 (unchanged)

NHS England’s Education Quality Team will continue to monitor the sustainability of improvements via the existing Mandatory Requirements (MR) on the Quality Management Portal (QMP), as well as the additional MR at the end of this report.

Review overview

Background to the review

Alongside the open actions on the quality management portal (QMP) for multiple medicine specialties following the review of Acute Internal Medicine in January 2025, and the self-report submissions for medicine specialties based on the General Medical Council’s (GMC) National Training Survey (NTS) 2024 results, NHS England felt that although improvements had been planned and/or implemented, the sustainability of these improvements was still of concern.

As a result, NHS England scheduled this Senior Leader Engagement Visit (SLEV) to discuss the measures outlined within the self-report submissions and the Trust’s plans moving forward to ensure the sustainability of these improvements. NHS England intended to facilitate a collaborative conversation with the Trust and to support them moving forward in their improvement plans.  

At this SLEV, medicine specialties included in the discussion were: 

• Acute Internal Medicine 
• Endocrinology and Diabetes Mellitus 
• Gastroenterology 
• General Internal Medicine 
• Geriatric Medicine 

• Internal Medicine Training Stage One 
• Respiratory Medicine 

The Trust provided the following evidence in preparation for this review:

The Trust provided some evidence in preparation for this review, including documentation around:

• Exception Reporting
• Freedom to Speak Up Board Report
• Incident Reports
• Internal Action Plans
• Local Faculty Group Meeting Minutes
• Quality Improvement Reports and Papers
• Student Feedback

Who we met with

Education team:

• Chief Executive (North Middlesex University Hospital)
• Clinical Director (North Middlesex University Hospital)
• Medical Director (North Middlesex University Hospital)
• Director of Medical Education (North Middlesex University Hospital)
• Assistant Director of Medical Education and Development (North Middlesex University Hospital)
• Medical Education Manager (North Middlesex University Hospital)
• Three Department Education Leads for Endocrinology and Diabetes Mellitus, Respiratory Medicine and Renal Medicine (North Middlesex University Hospital)
• Training Programme Director (North Middlesex University Hospital)
• Two College Tutors (North Middlesex University Hospital)
• Head of Quality (Postgraduate Medical Education) (Royal Free London NHS Foundation Trust)

Review panel

• Dr Vivienne Curtis, System Dean – North Central London, Education Quality Review Lead. NHS England – London
• Dr Elizabeth Carty, Interim Postgraduate Dean – London. NHS England – London
• Dr Catherine Bryant, Head of the London School of Medicine. Specialty Expert. NHS England – London
• Nicole Lallaway, Education Quality Coordinator. NHS England – London    

Review findings

The Trust delivered a presentation to the NHS England review panel detailing a summary of the improvements made since the last NHS England quality review in January 2024, and it was encouraging to hear of the continued improvement work taking place within North Middlesex University Hospital.

Quality Assurance and Local Faculty Group Working

The review panel were pleased to hear that a new proactive approach to Local Faculty Group (LFG) meetings was devised to facilitate constructive feedback from resident doctors (RDs). It was reported that previous LFG meetings were too large, with the inclusion of all of the medical specialties and resulting minimal attendance from RDs. With the new approach, the Trust had organised smaller LFG meetings for each of the different medical specialties, which was supported with LFG meeting templates that were now used more broadly across the Trust. This provided an opportunity for RDs to feedback on specific issues within the specialty and enabled the College Tutors to determine common themes across all of the medical specialties when comparing LFG minutes.

Improved Wellbeing

With regards to the wellbeing of RDs, it was reported that a number of projects were in place to promote improvements. This included the appointment of wellbeing leads, a therapy pet programme, improved Mess facilities, annual Medical Education Excellence Awards, Greatix Awards and a Summer Fair. The panel also heard that the Trust had good engagement from the Resident Doctor Forum, who were committed to making improvements via the forum as well. RDs working in medicine at North Middlesex University Hospital were reported to be very engaged and enthusiastic, with a focus on solutions to known issues within the Trust.

Emergency Department and Admissions

The Trust reported there were still some areas it was working on. This included some work looking at how to manage high numbers of acute admissions, the urgent and emergency care (UEC) recovery plan which aimed to improve performance within the emergency department (ED) and improve overall staff experience.

It was recognised that North Middlesex University Hospital was a busy organisation, but that it had increased opportunities for RDs and support for learning. It was also reported that the winter season in 2024 was challenging due to the volume of flu cases. The panel heard that the Trust was working with the Integrated Care Board (ICB) to improve system-wide working to manage emergency activity, with the creation of the Rapid Emergency Assessment Care Team (REACT) Hub in January 2025. It was reported that this hub enabled greater integration with community care to reduce the number of patients admitted via the ED, which would then reduce some of the pressure on RDs working in the ED.

NHS England Quality Management Portal Actions

The Trust felt it had made progress on closing actions on the Quality Management Portal (QMP). The postgraduate medical education (PGME) team developed a standard process with an excel template spreadsheet to monitor progress against actions, which included RAG rating actions. The panel heard that the PGME team worked closely with the medical departments and faculty on their actions to ensure that the requirements were clear. It was also reported that actions were fed into different Trust meetings where required, such as the Medical Assurance Workload Meeting, and that the PGME team felt they had good support from Senior Leadership on this work. 

Respiratory medicine

The panel heard that as a specialty, respiratory medicine gained two Internal Medicine Training (IMT3) RDs and had some higher specialty RDs working within the department as well. It was reported that there were still some issues regarding the consistency of ward cover, however the department was making improvements to the experience of RDs. The introduction of regular, informal teaching on the wards was felt to be of most benefit to RDs, and it was reported that the department had a good track record of developing IMT RDs into higher specialty RDs in respiratory medicine.

Endocrinology and diabetes mellitus

The panel heard that endocrinology and diabetes mellitus had three higher specialty RDs, three IMTs and some FY1 RDs working within the department. It was reported that the majority of issues raised was related to pressures in the emergency department. However, improvements were made regarding access to clinics for RDs, including streamlining clinics and reducing the number of clinics that were cancelled, increasing access to clinics, particularly for IMT RDs. The panel heard that this was a popular intervention amongst the IMT cohort, whereby IMT RDs were taken off the rota for the ward for one week every six months and spent that week working in clinics.

Renal Medicine

The panel heard that RDs working within renal medicine appeared to be engaged and enjoying their placement. However, it was reported that the RDs were busy and often pulled from working on the ward to cover acute medicine, which had impacted on continuity of care and ownership of patients.

Educational faculty

The panel heard that there was a quarterly postgraduate faculty committee meeting which invited all educational leads, and that this was a good forum to engage educational leads on improvements to training. It was also reported that time for educational supervision was regularly reviewed along with the job planning process, and that whilst not all educational supervisors had access to the correct amount of time, it was a work in progress. The panel also heard that there were opportunities to share resources and governance arrangements from the merger with Royal Free London NHS Foundation Trust, including the sharing of educational supervisor teaching sessions.  

Teaching for resident doctors

The Trust reported that local teaching for IMT RDs took place every Wednesday and that RDs were released from the rota to attend this. In addition, each department had its own specialty teaching available for RDs to access, with a grand round and acute medicine teaching for all RDs in a medical placement. The panel also heard that there were two coordinators organising regular Practical Assessment of Clinical Examination Skills (PACES) teaching, and that IMT RDs had access to this. However, the panel felt that it would benefit from assurance that IMT RDs were attending these teaching sessions.

It was reported that RDs were able to obtain feedback from consultants they worked with and had their workplace-based assessments signed off as required.

Post-take

The panel queried whether RDs were pulled from the wards to cover the post-take as this was a concern highlighted at the previous quality review in January 2024. The panel heard that there was guidance developed for post-take ward rounds (PTWR) and that there was a plan have a feedback loop to specifically monitor the PTWR noting that the acute medicine team had 2 consultants to manage the PTWR and that there was a designated space in the ED, with a 9am handover and huddles at 11am and 4pm in the ED to ensure that all patients in ED had been seen and management plans actioned.

The Trust reported that there were minimal instances in the past year of RDs being pulled in to cover PTWRs at short notice from other clinical areas, with 1-2 instances between August – September 2024, and none since then. It was reported that the Trust had increased staffing to mitigate this, with double the number of RDs rostered to do the post-take each day. Due to workload on the wards, the department sometimes had to fill gaps with locum doctors. The panel also heard that there was a WhatsApp group for the post-take ward round team, which included RDs and consultants, with screenshots shared from the rota to highlight who was working on the post-take each day. Feedback from the LFG meetings raised that despite this information being available, RDs were not always clear on who the clinically responsible consultant was for each day on the post-take, and the Trust felt that it needed to improve verbal clarification of who the responsible consultant was for each working day.

Facilities

The Trust reported that it had an ongoing challenge regarding space within the Trust for facilities for postgraduate training. The panel heard that an audit was undertaken which discovered there were many legacy meetings booked in the education centre which were no longer required, and this managed to free-up approximately 30% capacity for the rooms. However, it was recognised that facilities and space remained a work in progress.

Trust merger

In terms of the merger between North Middlesex University Hospital NHS Trust and Royal Free London NHS Foundation Trust, the Trust reported that the coordination of postgraduate programmes would remain site-based with no proposed changes. The panel also heard that the executive team at North Middlesex University Hospital would continue to be responsive to the needs of RDs, and that the Chief Executive would be North Middlesex University Hospital representative at the Royal Free Group Board meeting and advocate for education and training for the site. The previous People and Culture board was now called the People and Education Board, which was felt to have placed education as a larger focus within the hospital.

Areas for improvement

Mandatory requirements

Report approval

Report completed by: Nicole Lallaway, Education Quality Coordinator
Review lead: Dr Vivienne Curtis, System Dean – North Central London
Date approved by review lead: 19 March 2025

NHS England authorised signature: Dr Elizabeth Carty, Local Postgraduate Dean
Date authorised: 3 April 2025

Final report submitted to organisation: 4 April 2025