Promoting Excellence in Emergency Medicine Training 2025 Update: A Briefing for Clinicians
Executive Summary
This briefing synthesises the 2025 Royal College of Emergency Medicine (RCEM) standards for education and training, which aim to address significant challenges within the specialty, including high rates of burnout and attrition among trainees and trainers (1). The standards establish a framework for excellence, emphasising that high-quality patient care is inseparable from a positive learning environment that values and supports both learners and educators (1).
Key takeaways for clinicians and educational leaders include:
- Shared Responsibility: Quality in Emergency Medicine (EM) training is a shared responsibility across training sites, postgraduate EM schools, and individual trainees. Training sites must provide a safe, well-resourced environment, while schools manage programme quality and trainees engage as adult learners (1).
- Supervision is Paramount: High-quality supervision is fundamental to patient safety and trainee development. The standards mandate specific consultant-to-trainee ratios, require trainers to have protected time (0.25 PA per trainee) in their job plans, and recommend that trainees receive direct consultant supervision on a minimum of 50% of shifts (1).
- Protected Learning Time: Trainees must be allocated Educational Development Time (EDT) within their work schedules. The minimum recommendations are: 3 hours/week for ACCS, 4 hours/week for ST3, and 8 hours/week for Higher Specialty Trainees (ST4-6) (1).
- Environment and Culture: A positive safety culture is non-negotiable. Departments must have robust systems for raising concerns without fear of reprisal, learning from incidents, and ensuring adequate staffing and resources, including 24-hour on-site access to key supporting specialties like Anaesthetics, Intensive Care, and Acute General Surgery (1).
- Structured Training Experience: Rotations must be balanced to provide exposure to the full breadth of the curriculum, including paediatrics, trauma (with at least six months in a Major Trauma Centre or accredited Trauma Unit for HST), and a variety of departmental settings. Trainees must not be placed in isolation (1).
- Quality Governance: Both local and regional quality management processes are essential. Departments must have a Local Faculty Group (LFG) to monitor training, and postgraduate schools are responsible for ensuring all standards are met, with RCEM providing national oversight through mechanisms like ARCP externality (1).
Introduction
The RCEM's "Promoting Excellence in Emergency Medicine Training" document sets the standards for medical education and training within the specialty, updating the 2021 edition for 2025 (1). It operates within the quality assurance frameworks of the General Medical Council (GMC) and NHS England, aiming to standardise and improve the quality of EM training across the UK (1).
The document acknowledges the immense pressures on Emergency Departments (EDs), driven by escalating demand and increasing patient complexity. These pressures contribute to the high rates of burnout and dissatisfaction reported by EM trainees and consultants in GMC surveys, leading to significant attrition from training programmes. The standards are designed to counteract the erosion of educational opportunities and address national variations in training quality. They are intended to support regional postgraduate teams in setting clear goals for improvement where standards fall short, aligning with the NHS England Quality Framework and Intensive Support Framework (1).
The Learning Environment: Foundations for Quality Training
A safe and supportive learning environment is the bedrock of effective training and is inextricably linked to patient safety (1).
Workload, Staffing, and Resources
- Balance: There must be a balance between service provision and educational opportunities. While patient needs are the priority, work undertaken by trainees must support learning and not be dominated by routine tasks with little educational value (1).
- Staffing Levels: Medical staffing should work towards the standards set by RCEM's Guidelines for the Provision of Emergency Medical Services (GPEMS). There must be enough suitably qualified staff to ensure safe patient care, appropriate supervision, and manageable working patterns (1).
- Rota Design: Rotas must be designed to provide appropriate supervision, support professional development, minimise fatigue, and give trainees access to their educational supervisors. The use of self-rostering and resources like "EM-POWER: A practical guide to flexible working and good EM rota design" is encouraged. Trainees' hours must comply with the Junior Doctor Contract (1).
- Rest: Departments are expected to support trainee wellbeing by providing appropriate sleep and rest facilities, in line with the #RestEM campaign (1).
Physical Environment and Equipment
EDs must be adequately equipped to provide high-standard care and training. This includes:
- A dedicated and fully equipped resuscitation area.
- Adequate space and equipment for patients with less serious conditions.
- A room and trained staff for bereaved relatives (1).
- Specialist Facilities: Where applicable, facilities must comply with national standards for the care of children ("Facing the Future" standards), and for patients with mental health needs ("Mental Health in Emergency Departments toolkit") (1).
Essential Supporting Specialties
To ensure patient safety and provide a comprehensive training experience, the following specialties are expected to be available on-site 24 hours a day:
- Anaesthetics
- Intensive Care
- Acute General Medicine
- Obstetrics
- Coronary Care
- Acute General Surgery (with a consultant-led operating theatre available 24/7)
- Orthopaedic Trauma
- Paediatrics (if children are seen)
- 24-hour Radiology
- Haematology, Chemical Pathology, and Blood Transfusion services (1).
The absence of these on-site services increases clinical risk for trainees. Robust and reliable transfer systems and clinical support protocols must be demonstrable. An altered case mix due to ambulance diversion may restrict training opportunities, potentially limiting the time a trainee can spend in that unit (1).
Departmental Safety Culture
A positive safety culture is mandatory. The department must demonstrate:
- An environment where learners and educators can raise concerns about patient safety, care standards, or training quality without fear of adverse consequences.
- Immediate and effective responses to any safety concerns.
- A culture of learning from mistakes through effective incident reporting, reflection, and clinical governance.
- Support for the development of communication skills aligned with the duty of candour.
- Active seeking and responding to feedback from learners and educators (1).
Educational Structure and Opportunities
A structured approach to education ensures trainees can meet all curriculum requirements (1).
Induction, Handover, and Teamwork
- Induction: All learners must receive a formal induction covering their duties, supervision arrangements, their role in the team, how to access support, key policies, and how to raise concerns (1).
- Handover: Handovers must be organised to ensure continuity of patient care while maximising learning opportunities, without placing undue pressure on clinicians at the end of a shift (1).
- Teamwork: A culture of learning and collaboration between specialties and professions is essential. The educational needs of trainees must be recognised as a priority by hospital management (1).
Protected Learning Time and Resources
Trainees must have protected time for learning and development.
Trainee Level | Minimum Recommended Educational Development Time (EDT) |
ACCS | 3 hours per week (or 60 hours per 6-month block) |
ST3 | 4 hours per week (or 160 hours per annum) |
HST (ST4-6) | 8 hours per week (or 320 hours per annum) |
Pro-rata for Less Than Full Time (LTFT) trainees. |
In addition to EDT, departments must:
- Release specialty trainees for formal regional teaching.
- Provide adequate time and resources for workplace-based assessments, in line with CEED (Valuing Assessment) principles.
- Ensure ST3-6 trainees have allocated office space with computer and telephone access.
- Provide access to funding and study leave in line with regional policy (1).
Specialised Training Opportunities
Departments are expected to provide structured opportunities for trainees to develop skills in key areas as required by the curriculum:
- Teaching & Supervision: Gaining experience in teaching junior colleagues and medical students.
- Procedural Sedation: Achieving confidence and competence in a range of sedation skills.
- Ultrasound (POCUS): Gaining skills as per the RCEM curriculum, with departments following RCEM POCUS governance guidance.
- Leadership & Management: Engaging with the EMLeaders framework and gaining supervised experience in leadership.
- Quality Improvement (QI): Active involvement in departmental QI and audit programmes, including leading a project during higher training.
- Research: Access to advice and support for research projects within the region (1).
Supervision and Educational Capacity
Effective supervision is central to the RCEM standards, directly impacting patient safety, trainee development, and workforce retention (1).
Defining Educational Capacity and Trainer Ratios
Training capacity is determined by the ability to provide high-quality supervision.
- Trainer Job Planning: Named trainers must have 0.25 PA per trainee allocated in their job plans for educational responsibilities (1).
- Consultant Staffing:
- General EDs must have at least two substantive FRCEM consultants on the specialty register to be recognised for EM training.
- For Higher Specialty Trainees (ST4+), there should be at least one consultant per trainee and one FRCEM Educational Supervisor for every two trainees at ST4 level or above (1).
- Direct Supervision: RCEM recommends a minimum of 50% of shifts have direct clinical supervision by an EM consultant for all trainees (1).
- Other Trainees: Specific ratios also apply to Advanced Clinical Practitioner (ACP) and CESR trainees, who require one consultant per trainee and specific trainer accreditation (1).
The Core Functions of Supervision
Good supervision serves three main functions, which can be remembered with the mnemonic Q.L.W.
- Normative (Quality): Ensuring the supervisee provides high-quality and safe patient care.
- Formative (Learning): Facilitating workplace learning through high-quality, timely feedback.
- Restorative (Wellbeing): Enhancing the wellbeing of the supervisee (1).
Supervisor Roles, Responsibilities, and Support
Every trainee must have an allocated Educational Supervisor (ES) and a Named Clinical Supervisor (NCS).
- Eligibility: An ES or NCS must be a substantive EM consultant for over one year, be GMC-recognised as an appropriately trained supervisor, undergo annual educational appraisal, and have relevant equality and diversity training (1).
- Local Faculty Group (LFG): Departments should have an LFG (or Specialty Training Committee) with trainee representation that meets regularly to discuss the training environment and trainee progress. This group provides regular feedback via Faculty Educational Governance Statements (FEGS) (1).
- Examiner Presence: Departments training ST4+ level trainees should have at least one FRCEM Examiner (1).
Workplace Supervision Standards
Clear and reliable supervision and escalation pathways are essential at all times, including out of hours.
- ST1-3 Trainees: Must be able to contact a trainee or trainer of ST4 level or above for immediate attendance if required (1).
- ST4+ Trainees: Must be able to contact their appropriately qualified clinical supervisor (usually an EM consultant) for advice or attendance at all times (1).
Programme Management and Trainee Responsibilities
The successful delivery of training requires effective programme management by the EM School and active engagement from the trainee (1).
Training Programme Structure and Progression
- ACCS: The first two years comprise 6-month placements in EM, Acute Medicine, Anaesthetics, and Intensive Care Medicine (1).
- Intermediate Training (CT3/ST3): A 12-month period covering paediatric EM and general EM competencies (1).
- Progression: To progress from ST3 to ST4, trainees must have successfully passed MRCEM and have an Outcome 1 ARCP for ST3 (1).
- Sub-specialty Training: Nationally competitive training is available in Paediatric EM (PEM) and Pre-Hospital EM (PHEM). Dual accreditation with Intensive Care Medicine is also an option (1).
Designing Balanced and Supportive Rotations
It is the responsibility of the EM School to coordinate rotations that allow trainees to meet all curricular competencies.
- Balanced Exposure: Rotations must account for variations in case mix and ensure adequate training in the care of children and trauma management.
- Paediatrics: No Higher Specialty Trainee (ST4-6) should spend all three years in an adult-only department (1).
- Trauma: During ST4-6, trainees should spend at least six months in a Major Trauma Centre (MTC) or an accredited Trauma Unit with ring-fenced trauma experience (1).
- Peer Support: Trainees should not be placed in training sites in isolation. A minimum of two ACCS and/or two ST3-7 trainees should be placed in any one site to provide peer support (1).
The Trainee's Role in Their Own Development
As adult learners, doctors in training are responsible for:
- Familiarising themselves with the RCEM curriculum and assessment requirements.
- Keeping an up-to-date e-portfolio, including a diary of their EDT.
- Actively participating in workplace-based assessments and appraisal.
- Managing their own learning requirements and awareness of CCT timelines (1).
Pastoral Support, Wellbeing, and Inclusivity
Training programmes must ensure learners have access to educational and pastoral support.
- Resources: This includes confidential counselling services, careers advice, and occupational health services (1).
- Culture: Learners must not be subjected to behaviour that undermines their professional confidence, performance, or self-esteem (1).
- Adjustments & Flexibility: Reasonable adjustments must be made for learners with additional needs. Access to less than full-time training (LTFT) and supported return to training after a break must be available (1).
Quality Governance and Assurance
Robust governance at local, regional, and national levels is required to monitor and maintain training standards (1).
Responsibilities of the Training Site
EDs and their parent organisations are responsible for:
- Having effective and transparent educational governance systems.
- Ensuring those in educational leadership roles have demonstrable credibility.
- Collecting and acting on feedback from learners and educators.
- Sharing information about quality management with other responsible bodies.
- Escalating any safety, wellbeing, or fitness-to-practice concerns about a learner to the postgraduate school or Director of Medical Education (DME) (1).
The Role of the Regional Postgraduate School
The postgraduate school is responsible for:
- Ensuring the quality of educators through proper training, appraisal, and support.
- Monitoring local training quality via trainee feedback, ARCP outcomes, examination results, and differential attainment data.
- Providing support for trainees and ensuring equality, diversity, and inclusion.
- Overseeing opportunities for LTFT and supported return to training (1).
National Oversight and Review Mechanisms
Quality assurance is a national process involving:
- Annual Surveys: All trainees and trainers are expected to complete the GMC National Training Survey annually (1).
- RCEM Training Standards Committee (TSC): The TSC works with EM Schools to quality assure training, provides externality for ARCPs, and collates national data to support workforce planning and quality improvement (1).
- ARCP Externality: RCEM provides external representatives for a sample of ARCPs to ensure national standards are applied consistently. Reports are fed back to the Head of School and Postgraduate Dean to drive learning and improvement (1).
References
- Royal College of Emergency Medicine Training Standards Committee. Promoting Excellence in Emergency Medicine Training. London: RCEM; 2025.
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