Executive summary
Resident doctors identified some positive aspects of their training, however there a number of areas where improvements to the delivery of General Internal Medicine (GIM) training at University Hospitals Coventry and Warwickshire NHS Trust (UHCW) are required.
Areas identified as working well include:
- Strong educational governance structures at Trust level with clear reporting lines to the trust board and effective financial oversight of education budgets.
- Educational supervisors feel valued and well-supported with appropriate protected time allocated in job plans and adequate funding for their educational responsibilities.
- Good collaborative working relationships between the education team and specialty schools.
- Resident doctors would recommend the Trust as a place for clinical care, indicating confidence in the quality of patient care delivered.
Significant concerns requiring attention include:
- Patient safety issues requiring immediate action, including resident doctors working alone in the Emergency Department without consultant supervision, patients waiting in excess of 14 hours for consultant review and a lack of comprehensive handover systems creating risks of missed or delayed patient care.
- No structured GIM training programme beyond acute medical on-call duties, with limited access to general medicine outpatient clinics and learning opportunities.
- Inconsistent allocation and identification of GIM educational supervisors, with many resident doctors uncertain about their supervision arrangements
- Absence of GIM-specific induction processes and training plans, with no systematic coverage of GIM curriculum requirements
- Limited systematic monitoring of GIM training quality, with less rigorous analysis and response to GIM concerns compared to specialty training programmes.
The Trust demonstrates a strong commitment to education at an organisational level. However, the patient safety concerns, and the lack of structured GIM training, need addressing to ensure both appropriate learner support and that the required educational standards are being met.
Based on the concerns identified regarding patient safety, inadequate supervision arrangements, and the improvements required to the structure of GIM training, it will be recommended that an Intensive Support Framework (ISF) category 2 rating is applied. A Trust improvement plan will be required against the mandatory requirements outlined in this report, with regular progress updates and close monitoring of implementation.
Review overview
Background to the review
Further to the release of the 2024 GMC National Training Survey (NTS) results, the West Midlands (WM) School of Medicine scheduled this review to better understand the provision of GIM training at UHCW.
Who we met with
Learners
- Group 1 resident doctors in GIM
Educators
- Educational supervisors and clinical supervisors responsible for GIM training
- Consultants involved in the acute medical take and GIM supervision.
Education team
- Director of Medical Education
- Head of Medical Education
- Educational Leads
- College Tutors
- Medical education team representatives
Review panel
- Head of School (Medicine) WT&E, NHS England WM
- Deputy Head of School (Medicine) NHS England WT&E, WM
- Training Programme Director, NHS England WT&E, WM
- Deputy Quality Manager, NHS England WT&E, Midlands
Review findings
The quality intervention identified some positive aspects of the training programme, however there a number of areas where improvement is required across multiple domains of educational provision and patient safety.
Patient safety and clinical supervision arrangements
Resident doctors reported significant concerns regarding supervision arrangements in the Emergency Department (ED). Following the geographical separation of the ED and Acute Medical Unit (AMU), resident doctors described being regularly deployed to the ED to manage medical patients whilst working in isolation from consultant support. Resident doctors stated that consultant reviews are limited to patients in resuscitation areas, with those in majors and ED side rooms not receiving routine consultant oversight. This arrangement leaves resident doctors managing complex medical patients without appropriate senior clinical support, creating potential risks to patient safety.
Resident doctors consistently reported the absence of structured post-take ward rounds. They described situations where patients admitted to ED may wait up to 24 hours for consultant review, significantly exceeding Royal College of Physicians guidance of consultant review within 14 hours of admission. Resident doctors provided specific examples of unwell patients experiencing prolonged delays in consultant assessment, raising serious concerns about potential patient harm.
Resident doctors also highlighted the absence of comprehensive handover systems and patient tracking mechanisms for the medical take. They reported that the lack of systematic patient lists and handover processes results in patients being missed or receiving delayed care, creating risks of clinical deterioration, missed diagnoses, and potential serious harm. The current arrangements do not ensure that all medical patients can be reliably identified and tracked to guarantee necessary clinical reviews and treatments.
General internal medicine training structure
Resident doctors consistently reported that GIM training lacks structure beyond acute medical on-call duties. They described an absence of a formal GIM training programme that would provide systematic learning opportunities across the breadth of general medicine. Resident doctors stated that their GIM experience is limited to acute medical take activities, without planned exposure to outpatient general medicine, chronic disease management, or other core GIM competencies.
Educational supervisors acknowledged the challenges in delivering comprehensive GIM training. Trainers reported that whilst they provide specialty-specific training programmes, the GIM component lacks the same level of structure and planning. Some educators stated that GIM and specialty training meetings occur together rather than as separate focused sessions, potentially diluting the specific GIM educational content and planning.
The education team confirmed variability in GIM training provision across different specialties. They reported that whilst some specialties attempt to provide flexible training opportunities, there is no standardised approach to ensuring all resident doctors receive equivalent GIM training experiences regardless of their base specialty.
Educational supervision and support
Resident doctors reported inconsistent allocation and identification of GIM educational supervisors. Many stated that their educational supervisor arrangements are primarily focused on their specialty training, with unclear or absent specific GIM supervision arrangements. Some resident doctors reported uncertainty about who their designated GIM educational supervisor is, or whether they have one at all.
When asked about GIM-specific induction and training plans, resident doctors consistently reported that these do not exist. They stated that they do not receive specific GIM induction covering the expected experiences, learning objectives, or evidence requirements for the GIM component of their training. Monthly educational supervisor meetings, where they occur, were reported to focus on specialty training rather than systematic review of GIM progression and development needs.
Educators confirmed that GIM-specific educational supervision arrangements are not consistently established. They reported that whilst they provide educational supervision for specialty training, the GIM component is often addressed as an adjunct to specialty supervision rather than through dedicated GIM-focused meetings and planning. As a result, the generic capabilities in practice (CiP) requirements within the curriculum have not been explicitly addressed.
Learning opportunities and clinical experience
Resident doctors reported limited access to general medicine outpatient clinics (or being able to consistently attend clinics of other specialties in lieu of ‘general medicine’ clinics) and learning opportunities beyond the acute medical take. They stated that opportunities to observe and participate in chronic disease management, preventive medicine, and other core general medicine activities are rare or absent. This restriction significantly limits their exposure to the breadth of general medicine practice required for their curriculum.
The lack of structured handover training and utilisation of handover as a learning opportunity was consistently reported. Resident doctors described handover as a primarily administrative process rather than an educational experience that could enhance their understanding of clinical reasoning, prioritisation, and communication skills.
Resident doctors stated that feedback on their acute medical take performance is limited and inconsistent. They reported that whilst they may receive feedback on specialty-specific activities, there is little structured feedback or developmental discussion about their GIM clinical skills, decision-making, take management skills, or professional development within the general medicine context.
Quality monitoring and improvement
The education team acknowledged limitations in systematic monitoring of GIM training quality. They reported that whilst strong governance structures exist at Trust level for education overall, the specific monitoring of GIM training delivery and quality is less well-developed. Quality assurance processes were described as more robust for specialty training than for the GIM component.
Educators reported variability in their awareness of GIM curriculum requirements and their confidence in delivering appropriate GIM training. Some trainers stated uncertainty about the specific expectations for GIM training and the evidence requirements that resident doctors should be gathering during their placements.
The education team confirmed that whilst they collect feedback through various mechanisms, the specific analysis and response to GIM training concerns has been less systematic than for other training programmes. They acknowledged that this has contributed to the persistence of some of the identified issues.
Areas that are working well
| Description |
|---|
| Strong educational governance structures The Trust demonstrates robust educational governance at organisational level with clear reporting lines to board level, effective education committees, and systematic financial oversight of education budgets. The education team reported well-established processes for managing educational resources and ensuring appropriate allocation of funding. |
| Valued supervision roles Educational supervisors reported feeling valued by the Trust with appropriate protected time allocated in job plans and adequate funding for their educational responsibilities. Trainers stated they receive departmental support and feel their contributions to education are recognised and appreciated. |
| Collaborative working relationships The education team demonstrated good working relationships with specialty schools and external partners. They reported effective collaboration in planning and delivering educational programmes and responsive engagement with quality improvement initiatives. |
Areas for improvement
Immediate mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| Consultant supervision in emergency department It was reported that resident doctors are regularly based in the Emergency Department (ED) to provide care for medical patients and are working in isolation from the Acute Medical Unit (AMU). As a result, resident doctors reported that they do not receive appropriate consultant supervision including reviews of unwell patients. It was understood that consultants will review medical patients who are in resus, but do not routinely see ‘majors’ patients or those in ED side rooms. | The Trust must confirm arrangements to provide consultant supervision and support to resident doctors in ED. Evidence required that consultant reviews are available when required and happening in practice. | IMR1 |
| Post-take ward rounds It was reported that the lack of consultant presence in ED means there is no structured ward round that takes place for ‘majors’ patients that remain within the ED area. It was understood that patients may be discharged or transferred onto the wards without a consultant review which is out with the RCP guidance of a consultant review taking place within 14 hours of being admitted. | The Trust needs to ensure that there is a process in place for a post-take ward round for all medical patients, regardless of where they are located, within the required timeframes. | IMR2 |
| Handover processes It was reported that there is no comprehensive handover system or patient list for the medical take, and resident doctors reported that patients are being missed or receiving delayed care as a result, creating risk of clinical deterioration, missed diagnoses, and potential serious harm. | The Trust must ensure that all medical patients can be identified and are tracked to ensure that the necessary clinical reviews and treatments can be undertaken. | IMR3 |
Mandatory requirements
| Review findings | Required action | Reference number and or domain(s) and standard(s) |
|---|---|---|
| GIM training programme structure Resident doctors reported no structured GIM training programme beyond on-call duties. No formal GIM induction exists, and there are no specific GIM training plans or systematic learning opportunities outside acute medical take. | Develop and implement a comprehensive GIM training programme that includes structured learning opportunities, formal induction processes, and systematic coverage of GIM curriculum requirements. | MR1 |
| GIM educational supervision Inconsistent allocation of GIM educational supervisors with many resident doctors uncertain about their GIM supervision arrangements. No specific GIM training plans or regular GIM-focused educational meetings. | Establish clear GIM educational supervision arrangements for all resident doctors undertaking GIM training. Implement systematic allocation processes, specific GIM training plans, and regular GIM-focused educational meetings. | MR2 |
| Access to general medicine learning opportunities Resident doctors reported limited access to general medicine outpatient clinics and learning experiences beyond acute medical take. Lack of exposure to chronic disease management and broader general medicine practice. | Develop systematic access to general medicine learning opportunities including outpatient clinics, inpatient experience outside of main speciality, chronic disease management, and other core GIM experiences. Establish protected time and structured pathways for resident doctors to access these opportunities. | MR3 |
| Quality monitoring of GIM delivery Limited systematic monitoring of GIM training quality and learner experience. Absence of specific quality assurance processes for GIM component of training programmes. | Establish robust quality monitoring systems for GIM training delivery including regular learner and educator feedback collection, systematic review of training quality, and responsive improvement processes. | MR4 |
Recommendations
| Recommendation |
|---|
| Integration of dual accreditation specialty and GIM training Review and enhance integration between specialty training and GIM training to ensure coherent educational experience whilst maintaining distinct GIM focus and objectives. |
| Faculty development for GIM curriculum Develop faculty development opportunities specifically focused on GIM curriculum and training requirements to enhance educator confidence and capability in delivering high-quality GIM education. |
| Handover as educational opportunity Consider implementing handover as a structured educational opportunity with training for resident doctors in leading effective handover and providing systematic feedback on handover performance. |
| Resident doctor-led quality improvement support Consider engaging resident doctors in quality improvement projects to support implementation of IMR1, IMR2, and IMR3, including development of handover processes, patient tracking systems, and supervision protocols. This approach could enhance both patient safety outcomes and educational value through structured quality improvement methodology. |
Report approval
Report completed by: Kalpesh Thankey, Quality Deputy Manager, NHS England
Review lead: Prof. Phil Bright, Head of School of Medicine, NHS England
Date approved by review lead: 31 July 2025
NHS England authorised signature: Prof. Andy Whallett, Postgraduate Dean
Date authorised: 14 August 2025
Final report submitted to organisation: 4 September 2025