Transcript M+M January 2008

Junior Doctors in a 24/7 Working Hospital
Friday 27th November 2014
How does it work best for
training Junior Doctors?
Dr Tim Yates
Academic Clinical Fellow & Specialty Registrar in Neurology
Joint Deputy Chairman, UK Junior Doctors Committee
Dr Darshan H Brahmbhatt
Specialty Registrar in Cardiology & General (Internal) Medicine
Joint Deputy Chairman, UK Junior Doctors Committee
Conflict of Interest

DHB and TY are both doctors in training

Both of our hospitals work 24/7
Disclaimer
“A stranger is a leader in a foreign city” –
inscription, Ziggurat of Ur, c.2000 BCE
Overview

BMA Policy

Barriers to Training 24/7

Solutions: How to make it work best
(A sample of…) Relevant Policy
BMA Junior Doctors Conference, 2014
That this conference:
i) believes that, unless NHS funding is to expand, any move to 7-day services
should focus on improvements to unplanned out-of-hours care before
weekend elective working is considered;
ii) notes and supports calls from consultants for access to the full range of inhours facilities (such as radiographic, laboratory and other specialist services)
if they are expected to provide an extended consultant presence in the
interests of a safe and high quality service;
iii) demands that juniors be provided with the same resources if they are
expected to continue to provide 24-7 services;
iv) notes that important barriers to discharging patients out-of-hours (and
consequent hospital capacity issues) relate to the current working patterns of
other health and social care staff;
v) calls on the BMA to lobby governments to engage with all health unions to
come to a sensible solution to the benefit of patients.
(A sample of…) Relevant Policy
BMA Annual Representative Meeting, 2014
That this meeting:
i) recognises that many doctors already provide seven day emergency
services and insists that seven day urgent care must not be conflated with
seven day access to routine services;
ii) believes that delivery of both seven day routine and elective services is
not feasible within the current NHS budget constraints leading to reduced
clinical services Monday to Friday and/or closure of hospitals;
iii) insists that provision of seven day healthcare requires investment in
medical staff and supporting resources and not merely the reorganisation of
services;
iv) insists that any contract negotiations on seven day working must take
account of infrastructure and support services, compensation for antisocial
hours, and family friendly working.
(A sample of…) Relevant Policy
BMA Consultants Conference, 2013
That this conference agrees that the quality of care should be equally high
every day of the week but believes there is widespread misunderstanding of
the potential benefit of 'seven-day working', since consultant care is already
provided 24/7. Introducing elective work in evenings and at weekends would
require not only extra consultants (since the limit on consultant time is 48
hours per week) but also extra non-medical staff. This is likely to be
unaffordable in current financial circumstances. We call for an intelligent
debate and financial analysis of what could and should be done 'out of hours'
in acute hospitals.
Most (junior) doctors…
…already work out of hours
…understand the need to work weekend and
night shifts, but…
…don’t want to be routinely working nights and
weekends
…don’t want to be the only ones there
So how do we make this work?

1. Hours

2. Intelligent supervision

3. Stronger reporting structures

4. Empowered trainees
So how do we make this work?

1. Hours

2. Intelligent supervision

3. Stronger reporting structures

4. Empowered trainees
1. Safer Hours: WTR
Agreed implementation 1998, 1st limits 2007
with derogations, final limit 2009
 Should have been easy to operationalise and
assess but poor compliance after a decade

No data this has helped patient outcomes,
training outcomes, patient safety
 Trainee outcomes: more sleep, less training?
 No desire to see hours increase again

BMA 2006 Cohort in 2014
WTR implementation shows us
how working practice change
should not be done
Do we better understand how
working patterns place care and
training at risk?
- probably not
Smarter Hours: 24-7

Understand & manage fatigue
– Errors, reaction times
RESEARCH DEPENDENT
– Roman Generals
– Breaks, shift length, cover arrangements
– Facilities – rest, secretarial, administrative

Manage intensity
– Hot & cold
RESOURCE DEPENDENT
– But bad for training if too hot
– Time for reflection and abstract conceptualisation,
as well as doing/delivering service
– Staffing levels & skill mix
Safer, Smarter Hours: 24-7

Truly useful hours-reporting mechanisms
– Real time data
– Inform safe/unsafe limits
– Collated with national oversight
– Trainee satisfaction unlikely to be a good proxy

Accommodating self-declaration of fatigue

Culture and Systems
So how do we make this work?

1. Hours

2. Intelligent supervision

3. Stronger reporting structures

4. Empowered trainees
2. Supervision Level
24-7 agenda chance to bridge supervision gap
as well as service gap
 Consultant supervision the new normal – is
this best for training?

– Is there greater value in increased supervision
than there is in developed autonomy?
– eg should consultants routinely review the
ordering of all investigations by juniors?
– Most trainees would not regard such close
supervision as helpful – would consultants?
– Is near(er) supervision a better compromise?
Understand 24-7 Supervision
Enhanced supervision doesn’t always mean
reduced perceived autonomy, but when or
where pros outweigh cons is unknown
 Will lower levels of trainee autonomy &
responsibility today translate into better
patient care today? In 5 years?
 Must study impact on educational value and
quality of future care before trainees’
autonomy is irreparably restricted

WTR imposed inflexible working
changes that have altered training
practices without prior consideration
Trainees do not wish to fall into the
same trap again
Intelligent Supervision
Graded supervision from trainers, trainees
need to be treated as individuals by
systems
 Firm structure lost, therefore feedback
needs to work better to close the loop
 Improvements in rostering, to fulfill
training needs and meet service
requirements more intelligently

Intelligent Supervision (2)
Access to senior decision maker –
especially in acute care setting
 Hub and spoke, rather than linear
hierarchy
 Tailored development of trainee’s skills


But all of this needs time
So how do we make this work?

1. Hours

2. Intelligent supervision

3. Stronger reporting structures

4. Empowered trainees
3. Stronger Reporting Structures

Dysfunctional 24-7 potentially more
damaging than badly implemented WTR
Monitor hours – better systems to be
developed
 NTS (“the post”) – maturing

What about the person in the post?
 Must measure & reward the “right” things

If we can successfully measure
what we’re doing, we will know
when the changes we make
are the right ones
So how do we make this work?

1. Hours

2. Graded levels of supervision

3. Stronger reporting structures

4. Empowered trainees
4. Empowered Trainees

Trainees spend time learning things that
have no relevance for their practice

But not routinely taught safety culture/QI

Trainees lack the tools that should empower
them to influence organisation’s culture and
shape their 24-7 working environments
4. Trainees to Empower 24-7

They are simply not equipped to empower
24-7 working at present

And we don’t need to reinvent the wheel,
as several reports have already shown us
the path
So where do we go from here?
All the camps have pressing work to do
 Own the safety and training arguments

– Safe hours – employers, trainees
– Intelligent supervision – trainers, trainees, GMC
– Stronger reporting – employers, trainees, GMC
– Empowered trainees – trainees, trainers,
employers, GMC

Current employment contract & EWTD are
permissive to these changes
Thank You

Questions?

Contact Us:
[email protected]
[email protected]
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