Executive summary
Overall, feedback was positive with several areas working well and significant progress since the previous review. A small number of specific areas of improvement were identified. Resident doctors and trainers who had worked at the site over several years had observed improvements in the environment and training culture across medicine as a whole. Key contributing factors to this change included improvements in workload, staffing levels, educator support, and the general attitude towards education and training within departments.
Positive feedback and areas of improvement since the previous review were shared:
- Educational culture and learning opportunities – resident doctors reported there being a culture of teaching on the wards with lots of on-the-job training available across specialities, and well-established teaching programmes in place.
- Supportive environment – resident doctors reported they received good levels of support, supervision and feedback. Resident doctors were “busy but happy” and “loved the environment and culture” at the hospital which was considered warm and friendly.
- Trainer support – trainers felt supported and valued by the trust. Trainers advised that the focus on educator upskilling and development had contributed to the improved training culture.
- Educational governance – there were monthly meetings with the DME with all tutors across specialties, in addition to local faculty group meetings. The trust had an extensive supervisor accreditation process.
- Resident doctor forums – a network of chief residents to support the Chief Registrar was being established.
- Staffing and workload – resident doctors advised that both individual departments and the on-call rota were generally well-staffed. They felt the improved staffing levels had played a significant role in the more positive experience in comparison to previous reviews.
- Educational supervisor meetings – all resident doctors had met with their educational supervisors and discussed objectives and documented their plans for the placement.
- Work schedules – all resident doctors had work schedules and those who had worked at the site over several years had noticed an improvement in this key area.
Key areas that need to be reviewed and addressed:
- General internal medicine – general internal medicine experience is expected to include activity outside of a resident doctor’s specialty and acute on-call commitments.
- Induction – resident doctors had high praise for the local inductions held in August. Unfortunately, the experience and feedback from out-of-sync starters was less favourable.
- Emergency department assessment area (EDAA) – resident doctors were concerned by the overall standard of care provided in the EDAA and the potential for delays in treatment due to the generalised risk of handling such a high volume of patients.
- Educational supervisor meetings – good levels of educational supervision and interaction were not translating into meaningful report writing and portfolio entries.
- Self-development time – registrars advised that self-development time was not made explicit in their work schedules.
The majority of resident doctors recommended their training post. However, very few resident doctors would recommend the service due to high service demand and issues with patient flow at the point of admission. We acknowledge the efforts of the trust to encourage attendance at the review, however, it should also be noted that the turnout of foundation resident doctors was less than expected representing a low proportion of the total number of foundation doctors currently on placement across medicine.
Based on the overall review findings, improvements made since the previous review, and the positive change in culture, NHS England will be recommending this item is de-escalated from Intensive Support Framework (ISF) category 2 to ISF category 1. A trust improvement plan will be required against the mandatory requirements outlined in this report.
Review overview
Background to the review
In July 2022, during a review of acute medicine training at Queen Elizabeth Hospital, concerns were raised by resident doctors in relation to Birmingham Heartlands Hospital related to exception reporting, patient flow and staffing levels.
An education quality review was held in May 2023 and resident doctors reported a variable experience. Overall, morale was low amongst resident doctors and educators due to the heavy workload. Foundation teaching was reported to be of poor quality and foundation doctors had difficulty attending. Issues were raised with the facilities and lack of adequate rest and storage spaces.
A trust improvement plan was requested after the review and a follow-up learner educator meeting arranged for October 2024 to monitor progress and assess the current training environment for resident doctors at BHH.
Who we met with
Learners
- Higher, General Practice, Acute Common Care Stem (ACCS), Internal Medicine Training (IMT) and Foundation resident doctors
Clinical and Educational Supervisors
- Acute and general medicine supervisors
Education and Senior team
- Chief Medical Officer
- Director of Medical Education
- College Tutor
- Head of Medical Academy
- Chief Registrar
- Senior Quality Manager
- Quality Manager Postgraduate Medicine
Review panel
- Deputy Head of School (WM Medicine), Dr Gordon Wood, Education Quality Review Lead
- Training Programme Director – Quality (WM Medicine), Dr Amie Burbridge, Specialty Expert
- Foundation Programme Director (WM Central), Dr Julian Chilvers, Specialty Expert
- Quality Manager (Midlands), Raj Sunner, NHS England Education Quality Representative
Review findings
Educational culture and learning opportunities
Resident doctors reported a culture of teaching on the wards with lots of on-the-job training available across specialities, and well-established teaching programmes in place. Several specialties received praise from resident doctors for their positive training ethos: renal medicine, respiratory medicine, geriatric medicine, infectious diseases and acute medicine.
There were lots of learning opportunities and resident doctors felt they were progressing and hitting training targets and on track to meet their placement objectives. Consultants actively signposted resident doctors to learning opportunities. They were keen to discuss cases and complete CBDs and SLEs. Resident doctors appreciated the efforts of consultants in delivering training despite the high service pressures.
Local teaching programmes had strong consultant and registrar input and took place on a regular basis. Resident doctors reported no issues in terms of attending teaching sessions.
Supportive environment
The wellbeing champions were very well regarded by all doctors and their presence was appreciated.
Resident doctors reported they received good levels of support, supervision and feedback. They could access support overnight and foundation and IMT doctors valued the support given to them by medical registrars, especially overnight and on-call.
Resident doctors were “busy but happy” and “loved the environment and culture” at the hospital which was considered warm and friendly. Resident doctors felt valued, and several consultants were named as exceptional trainers and being particularly supportive.
Consultants and staffing groups from other professions were approachable, and multi-disciplinary team meetings were working well. Resident doctors praised the support of emergency department teams and consultants who often assisted with SDEC.
Staffing levels and workload
Resident doctors advised that individual departments and the on-call rota were generally well-staffed. They felt the improved staffing levels had played a significant role in the more positive experience in comparison to previous reviews.
Despite being busy the hospital was considered generally well-staffed. There was better general oversight and management of the rota compared to previous years and resident doctors normally finished on time. There was a conscious effort to encourage firm working where possible to enable doctors to build good working relationships.
Assessment sign-off
There was some variability in the responsiveness of consultants to completing ACATs and CBDs. Some consultants did struggle to complete assessments when overwhelmed with requests. Other trainers had encouraged the submission of assessments, but these were often not followed up and submitted by the resident doctor.
Trainer support
Trainers felt supported and valued by the trust, and reported they were able to fulfil their training duties in the time allocated for this purpose. The trust confirmed that work was ongoing to ensure consistency across departments in terms of the time available for trainers, especially for those that supervised multiple resident and locally employed doctors.
The trust reported on their progress to develop a cohort of committed and suitably trained educators. Educators acknowledged the wealth of resources and CPD opportunities available to them, and how they were actively being encouraged to take on educational and leadership roles.
Trainers advised that the focus on educator upskilling and development had contributed to the improved training culture in medicine as a whole. Furthermore, they considered there to be greater levels of collaboration and understanding between operational and educational groups within departments.
Educational governance
The trust’s Education team had worked hard to support departments and educators in delivering good training, despite the challenging healthcare environment, with visible educational leadership and governance in place. There were monthly meetings with the DME with all tutors across specialties. In addition to local faculty group meetings with educational leads and resident doctor representatives.
The trust has an extensive supervisor accreditation process that sets out a clear path to becoming a supervisor. Ongoing monitoring via a tracker provides an overview of the number of supervisors across departments and helps to ensure education and training skills are maintained and linked to appraisals.
General internal medicine
There was some confusion across groups as to what constitutes appropriate general internal medicine experience that is mandated by the curriculum and expected to include activity outside of a resident doctor’s specialty and acute on-call commitments. Further clarity on this matter was welcomed by all. The School of Medicine agreed to work with the trust to further clarify these requirements. It was anticipated that the planned general internal medicine specific forum would be a good platform to monitor progress in this area.
Induction
Resident doctors had high praise for the local inductions held in August that prepared them well for their ward and on-call duties. Unfortunately, the experience and feedback from out-of-sync starters was less favourable. There were logistical challenges and the online resources shared with out-of-sync starters were deemed to have limited value in preparing them for their duties.
LTFT resident doctors praised the support of medical staffing when starting out-of-sync. With the exception of GP resident doctors, all doctors received their rota with a minimum of six weeks’ notice. A dedicated induction for general internal medicine is in place. Pre-arrival contact with resident doctors took place in respiratory medicine and was well-received by doctors. The trust aims to roll this out to other specialties if viable.
The Education team advised of the intention to adapt and roll-out the solving problems and raising concerns (SPARC) guide used in surgery to wider specialties as a means to further improve the induction experience. The Education team described the checklist used by haematology that had received good feedback and guides doctors through various scenarios that they are likely to come across.
Resident doctor forum
There was a culture of listening and improving across programmes. Consultants and registrars were approachable and resident doctors were aware of their tutors and the Director of Medical Education. RDFs were in place for most specialties with regular meetings being held. Resident doctors were also aware of plans to introduce the general medicine specific forum.
A network of chief residents supporting the Chief Registrar was being established. Resident groups for ST3 and above were in place across specialties to close the loop on feedback from previous, more traditional JDFs, providing a “you said, we did” type of platform with clear feedback on actions, mitigations and closure of issues being raised across UHB.
Exception reporting
The number of exception reports had slightly increased recently. Resident doctors reported a general apathy to the process, but did not attribute this to any particular reasons. NHS England emphasised the importance of exception reporting to highlight areas of understaffing, promote wellbeing and protect training time.
Emergency department assessment area (EDAA)
Resident doctors were concerned by the overall standard of care provided in the EDAA and the potential for delays in treatment due to the generalised risk of handling such a high volume of patients. They were aware of audits and projects to improve the EDAA but remained concerned.
Trainers and the Senior team were well sighted on the issues with the EDAA. Mitigations were in place and the area was being monitored by regulators with regular reporting to the CQC and close working with the integrated care board (ICB). Trainers were committed to protecting resident doctors from risk and supporting their wellbeing. There were clear escalation points and oversight in place with a constant consultant and senior nursing presence.
Handover and post take ward round
Resident doctors described the recent change that meant they did not attend handover in the morning after a night shift and were required to join consultants for post take for 30 minutes at 8:00am. Resident doctors felt this had limited value due to fatigue. The Senior team confirmed that recent changes were made to enhance consultant interaction, however, it was acknowledged that this needed to be reviewed.
Educational supervisor meetings
All resident doctors had met with their educational supervisors and discussed objectives and documented their plans for the placement, including discussions on capabilities in practice (CiP) as applicable. Resident doctors were reminded that formal, high quality monthly meetings should be continuing throughout the placement period.
The good levels of educational supervision and interaction were not translating into meaningful report writing and portfolio entries. Write-ups for general medicine were of variable quality and did not reflect the excellent on-the-job training reported by learners. The quality of that being put forward to portfolios and reviewed at ARCP needed more work to adequately cover procedural, human factors and simulation aspects of the curriculum.
Work schedules
All resident doctors had work schedules and those who had worked at the site over several years had noticed an improvement in this key area. Clinics were generally embedded into schedules, with further work needed in cardiology and geriatric medicine. Some higher specialty resident doctors struggled with accessing clinic rooms to undertake independent clinics. IMT resident doctors had study leave built into their rota for gastroenterology and renal medicine.
Self-development time
Registrars advised that self-development time was not made explicit in work schedules. NHS England encouraged resident doctors to have conversations with supervisors and relevant staff to secure this time for their development, as well as submit exception reports if this time was impeded by service provision.
Facilities
Resident doctors described the new rest facilities as good. However, resident doctors felt the off-site location of the mess meant it was too far away in practical terms. Resident doctors advised that the rest and quiet rooms were often full during the deep hours of the night. Resident doctors were aware of plans to introduce lockers within acute medicine.
Areas that are working well
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
| Educational culture and learning opportunities Resident doctors reported there being a culture of teaching on the wards with lots of on-the-job training available across specialities, and well-established teaching programmes in place. Several specialties received praise from resident doctors for their positive training ethos: renal medicine, respiratory medicine, geriatric medicine, infectious diseases and acute medicine. Consultants actively signposted resident doctors to learning opportunities. They were keen to discuss cases and complete CBDs and SLEs. | 1.1, 1.13, 3.6, 3.7, 5.1 |
| Supportive environment Resident doctors reported they received good levels of support, supervision and feedback. They could access support overnight and foundation and IMT doctors valued the support given to them by medical registrars, especially overnight and on-call. Resident doctors were “busy but happy” and “loved the environment and culture” at the hospital which was considered warm and friendly. Resident doctors felt valued, and several consultants were named as exceptional trainers and being particularly supportive. The wellbeing champions were very well regarded by all doctors and their presence was appreciated. Consultants and staffing groups across professions were approachable, and multi-disciplinary team meetings were working well. | 1.1, 3.8 |
| Trainer support Trainers felt supported and valued by the trust, and reported they were able to fulfil their training duties in the time allocated for this purpose. Educators acknowledged the wealth of resources and CPD opportunities available to them, and how they were actively being encouraged to take on educational and leadership roles. Trainers advised that the focus on educator upskilling and development had contributed to the overall improved training culture in medicine. | 4.2, 4.3, 4.7 |
| Educational governance There were monthly meetings with the DME with all tutors across specialties. In addition to local faculty group meetings with educational leads and resident doctor representatives. The trust has an extensive supervisor accreditation process that sets out a clear path to becoming a supervisor. Ongoing monitoring via a tracker provides an overview of the number of supervisors across departments and helps to ensure education and training skills are maintained and linked to appraisals. | 1.1, 2.1 |
| Resident doctor forums A network of chief residents supporting the Chief Registrar was being established. Resident groups for ST3 and above were in place across specialties to close the loop on feedback from previous, more traditional JDFs. | 1.1, 2.1 |
| Staffing and workload Resident doctors advised that individual departments and the on-call rota were generally well-staffed. They felt the improved staffing levels had played a significant role in the more positive experience in comparison to previous reviews. Despite being busy the hospital was considered generally well-staffed. There was better general oversight and management of the rota compared to previous years and resident doctors normally finished on time. There was a conscious effort to encourage firm working where possible to enable doctors to build good working relationships. | 1.1, 5.1, 5.6 |
| Educational supervisor meetings All resident doctors had met with their educational supervisors and discussed objectives and documented their plans for the placement, including discussions on capabilities in practice (CiP) as applicable. Resident doctors were reminded that formal, high quality monthly meetings should be continuing throughout the placement period. | 1.1, 4.5 |
| Work schedules All resident doctors had work schedules and those who had worked at the site over several years had noticed an improvement in this key area. | 1.1, 5.6 |
Areas for improvement
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| General internal medicine There was some confusion across groups as to what constitutes appropriate general internal medicine experience. | Review and implement a means to ensure resident doctors obtain appropriate general medicine exposure in their placement. General internal medicine experience is to include activity outside of a resident doctor’s specialty and acute on-call commitments. Work with the School of Medicine to clarify curriculum expectations. | MR1 |
| Induction Resident doctors had high praise for the local inductions held in August that prepared them well for their ward and on-call duties. Unfortunately, the experience and feedback from out-of-sync starters was less favourable. There were logistical challenges and the online resources shared with out-of-sync starters were deemed to have limited value in preparing them for their duties. | Review the induction experience of out-of-sync starters and consider a face-to-face alternative to cover important content that is currently online for those unable to start in August. | MR2 |
| Emergency department assessment area (EDAA) Resident doctors were concerned by the overall standard of care provided in the EDAA and the potential for delays in treatment due to the generalised risk of handling such a high volume of patients | Ensure support is in place for resident doctors impacted by the ongoing and well documented challenges of EDAA, including clear wellbeing offers and escalation points. | MR3 |
| Educational supervisor meetings The good levels of educational supervision and interaction were not translating into meaningful report writing and portfolio entries. Write-ups for general medicine were of variable quality and did not reflect the excellent on-the-job training reported by learners. | Review and improve the quality of reports put forward to portfolios. These need to adequately cover procedural, human factors and simulation aspects of the curriculum. | MR4 |
| Self-development time Registrars advised that self-development time was not made explicit in work schedules. | In collaboration with resident doctors, secure self-development time within work schedules. | MR5 |
Recommendations
| Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
| Handover and post take ward round Resident doctors described the recent change that meant they did not attend handover in the morning after a night shift and were required to join consultants for post take for 30 minutes at 8:00am. Resident doctors felt this had limited value due to fatigue. In collaboration with resident doctors and consultants, review the effectiveness of recent changes to the handover/post take process to assess the potential impact and to ensure benefits are being realised. | 1.1 |
Report approval
Report completed by: Raj Sunner, Quality Manager (Midlands)
Review lead: Dr Gordon Wood, Deputy Head of School (WM Medicine)
Date approved by review lead: 14 November 2024
NHS England authorised signature: Prof. Andy Whallett, West Midlands Postgraduate Dean
Date authorised: 20 December 2024
Final report submitted to organisation: 24 January 2025