Executive summary

The results for the 2024 General Medical Council (GMC) National Training Survey (NTS) and the 2023 National Education and Training Survey (NETS) showed multiple categories where responses were below the national average at Royal Derby Hospital for resident doctors within Emergency Medicine. To better understand their experience of the clinical learning environment, a learner educator meeting was arranged for 17 October 2024.

Overall, resident doctors in Emergency Medicine described a mixed training experience.  They described the consultants as kind, supportive and excellent clinicians, however, they described the department as ‘overwhelmed with patients, understaffed, and not meeting the minimum safety standards most of the time.’ They reported that morale was low, with most staff including consultants, on the cusp of burnout. They described working in the department, referrals to specialties, and trying to get medical reviews as a constant battle and felt that despite working to their maximum capacity, they found it difficult to see the impact they were making.

Resident doctors and consultants in Emergency Medicine reported that there is currently no in reach team and that there is a lack of speciality ownership of patients. This is resulting in them providing prolonged patient treatment and management when the emergency medical assessment and treatment is complete. This raises concerns that emergency medicine staff are providing management for patients outside of their specialty and therefore outside of their training. This is also having a negative impact on the wait time to see a doctor within the emergency department. Resident doctors in Emergency Medicine also raised concerns about foundation year 1 resident doctors seeing patients by themselves without any senior input and therefore potentially discharging / admitting these patients unsupervised. These areas were raised as potential patient safety concerns following the visit.

Resident doctors spoke positively about the huge efforts over the last few months to address gaps in their training. They highlighted the Continuing Professional Development (CPD) clinics that had been recently organised by the speciality tutor as well as the efforts to provide Educational Development Time (EDT) time. All resident doctors were allocated educational supervisors, and educational meetings were taking place. They also spoke positively about the rota coordinators whom they found to be supportive.

Resident doctors spoke less positively about their induction and there was mixed feedback on the support for exception reporting. They described the rota as brutal and felt there was lack of structure to how the shifts run, a lack of clarity on roles and responsibilities, as well as a lack of handover procedures. They felt that learning opportunities and the ability to discuss cases in detail were lacking due to the pressure of service provision, and the educators also acknowledged that department pressures are significantly diluting the educational experience.

Both the resident doctors and educators described poor interprofessional behaviours and difficult interactions with other specialities when trying to refer patients which they found to be unacceptable and unhelpful.

To summarise, the areas to be addressed by the trust are as follows:

• Workload and staffing
• Rota and handover
• Exception reporting
• Learning opportunities
• Induction
• Culture

Based on the review findings, the panel will be recommending this item is increased from an intensive support framework (ISF) category 1 to ISF category 2 and added to the Quality Improvement Register.

A trust improvement plan will be required against the mandatory requirements outlined in this report. This should be submitted to england.qualityme@nhs.net by 20 December 2024.

Review overview

Who we met with

Learners

• Resident doctors in Emergency Medicine

Educators

• Clinical and Educational Supervisors in Emergency Medicine

Senior team

• Medical Director for Medical Education
• Specialty Tutor
• Divisional Medical Director
• Deputy Director of Medical Education
• Head of Medical Education Services
• Postgraduate Manager

Review panel

Education Quality Review Lead 

• Dr Mark Williams, Head of School for Emergency Medicine

Specialty Expert  

• Dr Umar Khan, Training Programme Director, Emergency Medicine

NHS England Education Quality Representative 

• Sarah Wheatley, Quality Deputy Manager

Review findings

Learning environment and culture

Resident Doctors in Emergency Medicine described their training experience as mixed.  They recognised that over the last few months there have been huge efforts made by the recently appointed Specialty Tutor to address the gaps in their training and improve the training experience. This was also echoed by the educators.

The resident doctors reported the department overall to be overwhelmed with patients and understaffed describing going to work every day to provide a service which ‘does not meet the bare minimum safety standards most of the time’. They felt that overall morale was low, most staff were on the cusp of burnout, and training opportunities were lacking because of the need to maintain service provision. 

The resident doctors in Emergency Medicine reported a poor induction overall with some having no induction at all. They described a lack of clarification about their roles and responsibilities when starting shift during induction.  

All resident doctors are aware of how to raise concerns; however, they reported that they had not had time to raise any since starting the rotation. There was mixed feedback on exception reporting with reports of some consultants being supportive, which contrasted with an example where a foundation doctor was criticised in front of others for exception reporting. They spoke positively about the rota coordinators who they felt were helpful, particularly the support received in organising a less than full time (LTFT) rota.  

Resident doctors spoke positively about the CPD clinic recently organised by the Specialty Tutor as well as offers from other consultants to provide these. They also highlighted the efforts for providing EDT time. Overall, they felt that getting assessments completed is possible, however, the opportunities for these could be difficult unless they are in the right place at the right time. They also reported that annual leave could only be taken when on a 7:30am start shift which they felt was the most opportune shift to get most learning opportunities and supervised assessments. The educators reported that due to service pressures and space, the opportunity to provide SIM teaching is difficult and recognised that there have been some cases that would have been of great benefit for learning. 

Both the resident doctors and educators described poor interprofessional behaviours and difficult interactions with other specialities when trying to refer patients which they found to be unacceptable and unhelpful.

Supervision and support

All resident doctors in Emergency Medicine have clinical and educational supervisors allocated and reported that educational supervisors are accessible, and educational meetings are taking place. They described the consultants as kind, supportive and excellent clinicians. Whilst they reported that some consultants are working hard to improve things, they felt that some of the consultants had lost their drive due to burnout.

It was reported that the support in resus was consultant dependant and that it sometimes felt like the resident doctors were coping rather than learning, with little opportunity to discuss cases in detail to understand what they were doing and why. 

The educators advised that they are allocated .25 PA for educational supervision for a maximum of 2 trainees which they appreciated, however, felt that some time for clinical supervision would also be beneficial. The educators felt supported by the postgraduate education team and described opportunities for educational forums, although these were reported to not always be accessible due to inflexibilities with dates and times. However, it was subsequently confirmed by the education team that they aim to provide sessions to suit most educators with 10 educator forums taking place each year over various days and times either virtual or face to face.

The educators acknowledged that department pressures are significantly diluting the educational experience they can offer and described finding it difficult to provide any opportunistic teaching or educational discussions due to service pressures.

The educators discussed being able to improve some of the pastoral support for trainees and acknowledged being reactive rather than proactive in providing that support to resident doctors.     

Workload and staffing

Resident doctors in Emergency Medicine described working in the department, referrals to specialties and trying to get medical reviews as a constant battle. Resident doctors reported that despite working to their maximum capacity, they found it difficult to see any impact they were making. They described huge queues, patients not moving on, and reviewing the same patients the following day because they are still the responsibility of the emergency department. Staffing levels were described as appalling at times, and there were also times when there is a lack of consultant presence. 

Resident doctors and consultants in Emergency Medicine reported that there is currently no in reach team and that there is a lack of speciality ownership of patients.  This is resulting in them providing prolonged patient treatment and management when the emergency medical assessment and treatment is complete. This raises concerns that emergency medicine staff are providing management for patients outside of their specialty and therefore outside of their training. This is also having a negative impact on the wait time to see a doctor within the emergency department. This was fed back as a potential patient safety concern following the visit

Resident doctors described that undertaking tasks such as writing up regular medications for patients’ entire stay, following up results, and prescribing courses of antibiotics were increasing the amount of time required per patient to ensure nothing is missed. They reported that this is resulting in some consultants feeling that those resident doctors who are clerking are being too slow and not seeing enough patients which is having a negative impact on morale. The educators also recognised that due to huge queues, the resident doctors are spending a significant amount of time writing up drug charts for patients and described no educational value in the ongoing monitoring of patients who have had their assessment completed. 

Resident doctors discussed the areas within the transfer hub where patients are awaiting a bed on Medical Assessment Unit (MAU) but are still under the care of Emergency Medicine for prolonged periods of time. They felt that there is a lack of structure to how the transfer hub is organised, leaving them concerned about how these patients will be managed when they finish shift. Overall, they felt that improvements to the organisation of the department would go a long way to improve morale. 

Resident doctors in Emergency Medicine also raised concerns about foundation year 1 resident doctors seeing patients by themselves without any senior input and therefore potentially discharging / admitting these patients unsupervised. This was raised as a potential patient safety concern following the visit.

Rota

Resident doctors in Emergency Medicine described the rota as ‘brutal’. They reported that multiple members of staff have called in sick every day for the past month. They felt that due to the enormous pressures of workload this is negatively impacting sickness levels and although they try and keep the department safe, they did not believe that this is sustainable. They described the department as small with a busy shift being 130 patients, however, they felt that the lack of organisation within the department prolonged the wait times.

It was reported by resident doctors that there is a lack of structure and organisation of how the shifts run, including who oversees which area and a lack of handovers. Although there is a main ED handover, there are no individual handovers within each area and varied shift start times lead to staff arriving at different intervals. This is resulting in a large amount of double working. Although there is a shift lead consultant and a registrar bleep holder, it is very consultant dependent on who does what. They also reported that it is unclear as to who the more junior resident doctors go to for review and gave examples of them ‘wandering around’ looking for someone. They also described the IT system as not fit for purpose.

A recurring issue reported was that in areas requiring relief such as resuscitation, the replacement is often sent exactly when the shift ends, resulting in often leaving late. 

Areas for improvement

Immediate mandatory requirements

Mandatory requirements

Report approval

Report completed by: Sarah Wheatley, Quality Deputy Manager
Review lead: Dr Mark Williams, Head of School for Emergency Medicine
Date approved by review lead: 25 October 2024

NHS England authorised signature: Professor Jonathan Corne, Regional Postgraduate Dean, Midlands
Date authorised: 7 November 2024

Final report submitted to organisation: 2 December 2024