Executive summary
The intervention was well attended by all groups and overall feedback from resident doctors demonstrated progress on the improvement plan since the previous visit, although further improvements are needed in certain areas, including the management of outliers that was once again raised as a patient safety concern during the review.
Areas working well and good practice identified: Overall, resident doctors described a positive shift in the culture within the trust with resident doctors reporting that their experience in the trust had improved as they progressed in their rotation.
A dedicated office on the admissions unit is available for use by resident doctors who no longer compete for office space with other professions, leading to more cohesive working relationships.
The departmental Chief Residents received positive feedback from all groups and were described as driving change and “doing an amazing job”.
High level areas for improvement: The management of medical outliers remains a significant issue for the trust. The trust recognises the current outlier system is not functioning at optimum levels and were committed to making the necessary improvements.
Higher specialty doctors starting their placements out of step with foundation and IMT trainees found their induction to be inconsistent, lacking structure, and insufficient to support new doctors effectively.
Based on the overall review findings, it is recommended that the Intensive Support Framework (ISF) category 2 is de-escalated to an ISF 1. An improvement plan addressing the mandatory requirement outlined in this report will be necessary.
Review overview
Background to the review
In December 2019, concerns regarding the working and training environment within acute and general medicine at Queen Elizabeth Hospital were highlighted through the General Medical Council (GMC) national training survey (NTS). Additionally, resident doctors directly raised issues through the postgraduate medical school. Key concerns included a challenging working environment, limited educational opportunities, and a poorly structured acute medical take.
Following these concerns, between January 2020 and June 2023, a series of learner educator meetings were conducted to assess progress in addressing the identified issues. The trust was required to submit an improvement plan demonstrating clear actions to resolve the concerns raised.
Following the June 2023 learner educator meeting, while improvements and progress were observed, issues persisted in areas such as induction, rotas, facilities, and workplace culture. Additionally, a patient safety concern regarding delays in the management of medical outliers remained, unresolved.
A follow-up learner educator meeting was arranged for November 2024 to assess the current training environment.
Who we met with
Learners: GP and IMT doctors in acute and general medicine; Higher specialty doctors in training in acute and general medicine
Educators: Clinical and educational supervisors; Education team; The Educational team
Review Panel: Quality Review Lead – Dr Gordon Wood, Deputy Head of Postgraduate School of Medicine, NHS England; Training Programme Director – Quality – Dr Amie Burbridge, NHS England; Training Programme Director (Observing) – Dr Sabina Moolla, Co-TPD Internal Medicine, NHS England; Deputy Quality Manager – Joycelyn Boyce, NHS England
Review findings
Induction
While the induction process was generally considered satisfactory for GP and IMT resident doctors, some doctors noted that it could have been more comprehensive. GP and IMT doctors praised the quality of the geriatric medicine in particular.
The higher specialty doctors however, reported that when their placements started out of synch with the IMT and FY1 cohorts the induction process as inconsistent and insufficient. Inductions were deemed unstructured, overly informal and poorly organised by several resident doctors. Resident doctors experienced difficulties in obtaining essential IT credentials and access badges in a timely manner and were often organising their own inductions independently due to a lack of guidance and support.
Rota
The majority of the IMT and GPVTS trainees received their rotas on time although one trainee had to chase their upcoming rota as there was a delay in approval of their LTFT request. Other doctors were informed that half of the rota was invalid with a correct rota to be issued in December 2024, but this would be within appropriate notification time frame.
A notable change from the previous year was that doctors receive more weekends off. While they now work fewer weekends, they are expected to work longer weekdays which has resulted in fewer training opportunities. Rest days were reported as being randomly allocated and while on-call schedules have improved, there remains concerns about the overall scheduling process.
Higher specialty doctors reported receiving their rotas more than six weeks in advance, which allowed for better planning and preparation.
Education and training
The training culture was generally seen as good, and this was a noted improvement from previous visits. Opportunities for professional development were available to those who sought them, notwithstanding the difficulties with accessing clinics.
The educators reported the appraisal system did not foster a meaningful two-way conversation. There was a lack of reflection on past achievements, with limited discussion on training needs for the future and what would be beneficial for ongoing professional development. It was also reported there was a lack of clarity around roles and responsibilities, which hindered an effective allocation of time for teaching and training.
The educators reported feeling that their efforts in delivering educational training were appreciated by the resident doctors. However, they expressed not feeling adequately supported by the trust to deliver training effectively. They didn’t feel supported to get CPD for their education roles. Concerns were specifically expressed about the quality of CPD offered by the trust from external training providers, with many consultants describing it as poorly advertised and of poor quality which discouraged regular attendance at these sessions.
Despite this, the educators remained committed to providing high quality training and were dedicated to their roles. There was a strong sense of camaraderie, with educators actively supporting and collaborating with one another to overcome challenges and provide the best possible learning experience for resident doctors.
Those present were provided with a generic work schedule and were informed who their educational supervisor was. They met with their supervisor in a timely manner, and initial meetings were described as structured. They felt there was a focus on their educational needs. However, this was not consistent amongst all resident doctors, and it is apparent that there is a lack of standardisation across educational supervisor reports.
When asked the trainees and the trainers could not describe what GIM training looked like at the trust or how they would receive their GIM capabilities. While all doctors had a clear understanding of the difference between GIM training and speciality training, they indicated a lack of focus in their supervisor meetings for the GIM components.
Exception reporting
None of the resident doctors present had submitted an exception report, with several citing concerns about the lack of anonymity in the process, feeling that it would single them out. Additionally, there was a general lack of awareness regarding the procedure for exception reporting. Several resident doctors expressed they would have benefitted from a dedicated session explaining what exception reporting entailed and how it could be properly utilised.
Clinics
GP and IMT doctors reported having access to clinics and were assured of protected clinic time. Some doctors expressed reluctance to request time away from the ward due to concerns about the ward’s staffing levels that would ultimately result in an increased workload on fellow colleagues left on the ward. They noted that when the ward is particularly busy, it becomes difficult to leave for training or clinic commitments.
Higher specialty doctors also face significant challenges in attending clinics, citing ward pressures, and found themselves having to attend these clinics in their own time particularly taking study leave to attend GIM focused clinics. Consultants often emphasised ward patient safety must take precedence, resulting in higher speciality doctors feeling they are viewed and treated as a more junior grade.
Resident doctors felt that consultants covering the ward were not proactive in monitoring the rota to ensure resident doctors were able to attend their scheduled clinics, often relying on the goodwill of colleagues to facilitate their attendance. Finally, there are no dedicated GIM clinics.
Medical outliers
All groups who took part in the visit reported issues with the management of medical outliers. The resident doctors expressed familiarity with the outlier process but voiced several challenges. A recurring issue was the inconsistency in managing outlier patients. Nurses who were unsure of whom to contact for outlier issues, often reached out to the on-call staff.
When on-call a lack of clarity contributed to mismatched expectations between consultant and resident doctor roles, leading to confusion over who should be reviewing and managing the patients. It was also reported that the ward environment sometimes lacked sufficient information on outlier patients, which resulted in delays or missed assessments.
A particularly concerning issue relates to patients who are transferred to wards but are not flagged for follow-up. There is the potential for critical conditions, such as heart failure, being missed. It was reported that consultants often failed to take responsibility for patients, even if they disagreed with decisions made by previous teams, leading to a hands-off approach. This lack of accountability could also result in unsafe practices. The doctor emphasised that small oversights, which might seem minor at first, can have severe consequences to patient care.
Facilities
A dedicated office on the admissions unit is available for use by resident doctors who no longer compete for office space with other professions, leading to more cohesive working relationships.
Hot drinks are available in the mess, however, the absence of a hot drinks machine, especially during the night shifts was noted as an inconvenience.
Some doctors reported being aware of the trust’s fatigue policy but were unsure of how to access it. Furthermore, doctors were unaware that the trust’s fatigue policy should include provisions for overnight accommodation or taxi transportation home when necessary.
Culture and behaviours
Overall, doctors described a positive shift in the culture within the trust with resident doctors reporting that their experience in the trust had improved as they progressed. Resident doctors reported feeling valued and sensed a collective desire for positive change within the trust. The presence of departmental resident forums, where concerns can be raised and addressed, was seen as a positive development. The introduction of chief residents for all specialities was appreciated by resident doctors.
The Departmental Chief Resident received significant praise for advocating on behalf of colleagues and providing valuable feedback on concerns raised. All staff groups involved in the quality visit commended their leadership, with many recognising them for “doing an amazing job”.
No widespread bullying or inappropriate professional behaviours were reported by resident doctors, however, there remained isolated incidents affecting the work environment.
When asked whether they would recommend the trust as a place to train, all but one resident doctor responded positively. When asked about recommending the trust as a place to receive care, all doctors responded favourably.
Areas that are working well
| Description | Reference number and or domain(s) and standard(s) |
|---|---|
| Induction: GP and IMT doctors praised the quality of the geriatric medicine | 1.11 |
| Facilities: A dedicated office on the admissions unit is available for use by resident doctors who no longer compete for office space with other professions, leading to more cohesive working relationships. | 1.11 |
| Culture: Overall, resident doctors described a positive shift in the culture within the trust with resident doctors reporting that their experience in the trust had improved as they progressed in their rotation. A good training culture was reported and there is a strong sense of collegiality between the educators. When asked whether they would recommend the trust as a place to train, all but one resident doctor responded positively. When asked about recommending the trust as a place to receive care, all doctors responded favourably. | 1.1, 3.8 |
| Education and Training: Meetings between educational supervisors and higher speciality doctors were described as well structured, focusing on the resident doctors’ educational needs. All resident doctors were clear about the expectations for the year ahead, and felt they were performing tasks at the appropriate level for their role. There was a focus on their educational needs. | 2.1, 2.4 |
| Chief Resident: The Chief Residents received positive feedback described as “driving change and doing an amazing job”. | 2.1, 2.4 |
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| Medical outliers: A recurring concern raised by both resident doctors and consultants relates to the outlier system. They identified significant risks to patients who were under medicine but were sitting outside the designated medical bed base. Several examples were shared where the current outlier system directly contributed to negative outcomes, including actual harm, due to extended delays before receiving attention from the allocated doctor responsible for their care and treatment. There was also a lack of certainty as to who was responsible for which patient and a general concern that some complex patients were being cared for by doctors without the relevant specialty experience in the presenting condition required to progress care. | A trust response was requested and received. | IMR1 |
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| Induction: Higher specialty doctors reported their induction as inconsistent, lacking structure, and insufficient to support new doctors effectively. Key logistical tasks, such as obtaining ID badges and setting up IT access, were left to be handled independently, leading to confusion and frustration. | Further improvements to the induction process to support new staff members to properly integrate from the outset. | MR1 |
| Rota: Improvements have been made to rota scheduling, particularly with more weekends off, however, there are still challenges in terms of delays, rest day allocation, and overall consistency. Further improvements are needed to streamline the process and ensure better support for doctors. | Ensuring rotas are issued in advance to reduce frustration and improve the overall doctor experience. | MR2 |
| Clinics: All doctors face challenges in attending clinics, citing ward pressures. Higher speciality doctors felt consultants were not proactive in monitoring the rota to ensure they are able to attend their scheduled clinics. As a result, they struggled with balancing ward duties and clinic attendance. Those rostered for dedicated SPA days, reported difficulty in accessing this time, often relying on the goodwill of colleagues to facilitate their attendance. | Resident doctors should not be deterred from attending clinic or teaching sessions. Accessing both will enhance their training, growth and development. Resident doctors should be released from ward duties to attend these sessions. | MR3 |
| Training: The educator’s appraisal system was reported as not fostering a meaningful two-way conversation. There was a lack of reflection on past achievements, with limited discussion on training needs for the future and what would be beneficial for ongoing professional development. It was also reported there was a lack of clarity around educator roles and responsibilities which hindered the effective allocation of time for teaching and training. | The educator appraisal system should be structured to promote a constructive meaningful, two-way conversation. It should include feedback on past performance while offering a platform to discuss future training needs, career aspirations and development goals. | MR4 |
Recommendations
Recommendation | Reference number and or domain(s) and standard(s) |
|---|---|
Fatigue policy Many doctors are unaware of how to access the Trust’s fatigue policy, and there is a lack of clarity regarding its provisions for overnight accommodation or taxi transportation. Increase awareness of the fatigue policy ensuring all resident doctors are fully informed. Make the policy easily accessible, potentially including it into the induction process for resident doctors.
|
3.1, 3.9 |
Exception reporting No GP or IMT doctors had submitted exception reports, with several citing concerns about the lack of anonymity in the process, feeling it may single them out. There was also a general lack of awareness regarding the procedure for exception reporting. Resident doctors to be encouraged to exception report. Improved communications about the reporting system could encourage greater engagement with the process. |
1.7 |
Accommodation Access to accommodation is seen as cumbersome, requiring multiple email exchanges and the involvement of occupational health. There was also uncertainty regarding any limits to accommodation use. The accommodation request process to be simplified and streamlined to make it more efficient and user friendly. |
1.11 |
General internal medicine GIM activity is not incorporated into the rota or training schedule and there are no dedicated GIM clinics. The quality of educational supervisor documentation and GIM specific evaluations requires improvement, as well as the development needs of GIM supervisors ensuring that the GIM experience is properly developed and delivered.
|
4.4, 4.5 |
Work schedules It is recommended that a robust process to review, distribute and use the educational work schedules is implemented. |
3.6 |
Report approval
Report completed by: Joycelyn Boyce, Quality Deputy Manager, NHS England
Review lead: Gordon Wood, West Midlands Deputy Head of Postgraduate School of Medicine, NHS England
Date approved by review lead: 17 April 2025
NHS England authorised signature: Prof. Andy Whallett, West Midlands Postgraduate Dean
Date authorised: 22 April 2025
Final report submitted to organisation: 15 May 2025