Appropriate Junior Doctor Staffing Improves Patient Safety, Training and Doctor Wellbeing

C Daly, A Stevenson, A Thorne, J Fallon

Musgrove Park Hospital, Somerset NHS Foundation Trust, TA15DA

Background

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-of-hours patient care is provided by a doctor not normally working or training in the specialty. It occurs widely across the NHS, particularly in surgical specialties, and has implications for both patient safety and doctor wellbeing. Due to increasing general medical workload in our Trust, a decision was made some 15 years ago to reallocate found ation doctors from Trauma & Orthopaedics(T&O) and Ear, Nose and Throat surgery (ENT) to out-of-hours medical ward cover. This left one core surgical trainee or equivalent providing emergency cross-cover for all surgical specialties, including General surgery, Urology, Vascular surgery, ENT, T&O and Spinal surgery, resulting in an overwhelming and often unsustainable workload. Compounded by the pressure of providing emergency cross-cover for multiple unfamiliar specialties this situation led to negative trainee surveys, GMC reports and numerous Immediate Safety Concerns (ISC) and Exception Reports.

Methodology

This project aimed to improve patient care and post-graduate training through optimisingjunior doctor staffing in both the medical and the surgical directorate. Business cases were generated using data from GMC surveys, Exception Reports and recent ISCs, and presented to the Trust Board, highlighting the concerns and suggesting sustainable solutions. In essence, funding to hire a number of additional junior doctors would be required to create a new tier in the surgical out-of-hours rota. Recruitment of surgical clinical fellows would enable a split of T&O and Spinal surgery from the rest of the surgical out-of-hours workload. Recruitment of medical clinical fellows was also needed in order to repatriate foundation doctors back to their home specialties. The business cases were approved, and a new out-of-hours rotawas created and implemented in August 2021.

Qualitative evidence was gathered by surveying affected junior doctors before and after the change to assess its impact on doctor well-being and training as well as perceived patient safety. Quantitative analysis of Exception Reports and ISCs submitted during this period was also used as evidence to demonstrate improvement.

Results

The survey results following the change were overwhelmingly positive, showing a significant improvement in workload and rest breaks (Figure 1) and continuity of care for patients. Job satisfaction improved, with 81% of surgical junior doctors reporting they would recommend their job, compared with only 42% prior to the change (Figure 2). Foundation doctors in T&O reported higher levels of confidence and enhanced learning due to more consistent exposure to the specialty (Figure 3). There have been fewer Exception Reports (Figure 4) and no ISCs raised outof-hours in surgery since July 2021, compared with eleven in the previous 18 months.

Lessons

We have learned that historic short-term fixes such as the reallocation of foundation doctors to provide service provision within other departments can have detrimental long-term effects. This improvement project has shown that the use of data to demonstrate longstanding problems can help advocate for funding and systemic change that improves the welfare of patients and doctors alike.

Exception Reports for Working Hours within the Surgical Directorate