Author Archives: Roger Burns - retired GP

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

Burnout in healthcare: the case for organisational change

Analysis – Burnout in healthcare: the case for organisational change (Published 30 July 2019)  BMJ 2019;366:l4774 by A Montgomery, professor in work and organizational psychology et al.

Burnout is an occupational phenomenon and we need to look beyond the individual to find effective solutions….

Image result for burnout cartoon

Burnout has become a big concern within healthcare. It is a response to prolonged exposure to occupational stressors, and it has serious consequences for healthcare professionals and the organisations in which they work.1 Burnout is associated with sleep deprivation,2 medical errors,345 poor quality of care,67 and low ratings of patient satisfaction.8 Yet often initiatives to tackle burnout are focused on individuals rather than taking a systems approach to the problem.

Evidence on the association of burnout with objective indicators of performance (as opposed to self report) is scarce in all occupations, including healthcare.9 But the few examples of studies using objective indicators of patient safety at a system level confirm the association between burnout and suboptimal care. For example, in a recent study, intensive care units in which staff had high emotional exhaustion had higher patient standardised mortality ratios, even after objective unit characteristics such as workload had been controlled for.10

The link between burnout and performance in healthcare is probably underestimated: job performance can still be maintained even when burnt out staff lack mental or physical energy11 as they adopt “performance protection” strategies to maintain high priority clinical tasks and neglect low priority secondary tasks (such as reassuring patients).12 Thus, evidence that the system is broken is masked until critical points are reached. Measuring and assessing burnout within a system could act as a signal to stimulate intervention before it erodes quality of care and results in harm to patients.

Burnout does not just affect patient safety. Failing to deal with burnout results in higher staff turnover, lost revenue associated with decreased productivity, financial risk, and threats to the organisation’s long term viability because of the effects of burnout on quality of care, patient satisfaction, and safety.13 Given that roughly 10% of the active EU workforce is engaged in the health sector in its widest sense, the direct and indirect costs of burnout could be substantial.14

Shared problem

We need effective strategies for preventing and ameliorating burnout within healthcare settings. The most common responses have put the responsibility on healthcare professionals to take better care of themselves, become more resilient, and cope with stressors on their own. But such an individualistic approach can ignore the sources of chronic stressors in the workplace such as incivility, staff shortages, and austerity measures, which are often beyond an individual’s control. The exhaustion, cynicism, and consequent feelings of inefficacy experienced by people with burnout are often a shared experience in response to shared job stressors, and we should frame it as a systems problem, and not simply as an individual one.1

Individually focused solutions are important to support overburdened staff but are less likely to have longevity and sustainability than solutions that are organisationally embedded.15 They may even compound problems in the long run by reinforcing a dysfunctional coping approach that interprets failure as wholly personal. Locating solutions for organisational problems within individuals is common in healthcare, particularly with the physician culture that valorises inappropriate self care16 and the avoidance of emotionally challenging events.171819

The current focus on narrow definitions of burnout as a medical diagnosis and inadequate measurement approaches have hampered progress. Viewing burnout as a disease has hindered efforts to focus on the work place values that are driving burnout. In addition, a focus on the exhaustion component of burnout has overestimated some relationships and underestimated others, meaning that interventions are less evidence based. We discuss four practical steps to move us towards understanding burnout at a systems level and therefore implementing a systems approach to the problem: using burnout as an indicator of healthcare quality, assessing it at the departmental and the individual level, explicitly developing healthy workplaces, and including practitioners and patients in the process of articulating research questions.

Including burnout in assessments of healthcare quality

We need a different approach to integrate wellbeing as a quality marker within the healthcare system (such as the JAMA charter on physician wellbeing).20 We can think of hospitals measuring safety in four categories: structure (eg, facilities, organisational culture), process (eg, consistency of care), outcome (eg, survival rates), and patient experience (eg, satisfaction).21 In the UK, research among NHS staff indicates an almost universal desire to provide the best quality of care but also shows that organisations can find it difficult to obtain valid insights into the quality of the care they provide.22 However, better quality, safer care for patients has been linked to higher rates of staff engagement.2324 In addition, staff satisfaction is weakly correlated with hospital standardised mortality ratios.25 Medical departments reporting high levels of burnout could therefore be a signal of erosion of hospital safety. If burnout can be considered an indicator of organisational malfunctioning, it should be included in the assessment of healthcare quality. The World Health Organization’s recent recognition of burnout as an occupational phenomenon (and not a medical disease) opens the way for policy makers to fund organisational strategies aimed at research and amelioration.26

Measuring staff experience of work may help to understand organisational drivers of poor quality care. Leiter and Maslach describe five profiles of work experience, each suggesting a different approach to tackling the drivers of burnout and thus a different intervention and solution.27 There is a continuum from burnout (high on all three dimensions of dysfunction) to engagement (low on all three). The three intermediate profiles are disengaged (characterised by high cynicism only), overextended (high exhaustion only), and ineffective (high inefficacy only) (fig 1). Each profile reflects a different worklife crisis that would require a unique intervention strategy. The ineffective profile has been largely ignored, with most researchers focusing on exhaustion and cynicism. But feeling negatively about how well you are doing your job needs more than just a lighter workload and lunch with colleagues.

Conclusions

We need to widen our approach to tackling burnout. The challenge for health systems in an increasingly complex health environment, with the twin pressures of limited resources and increasing levels of burnout, is to develop interventions to counter the factors that are leading to burnout. The problem is not the workforce but the way that the environment is becoming toxic. Measurement of burnout can provide an early signal of a problem. Prevention, which is more desirable than treatment, will be enabled by a healthy workplace approach that includes both continuous evidence based assessment of burnout and action on the structural drivers of burnout tailored to staff experience and co-designed with input from the users of the health service.

Key messages

  • Burnout is an occupational problem not a medical diagnosis

  • Healthcare organisations should assess burnout at departmental level and use it as a metric of safety of care

  • More focus is needed on developing healthy workplaces

  • Staff and patients must be included in developing actions to reduce and prevent burnout

  • Image result for burnout cartoon

Farting into a thunderstorm: putting good money after bad and without the “discussion” needed

The announcement by the Prime Minister (note not the Minister of Health) that there would be more money for the 4 health services is deceptive and disingenuous. There are not enough people/staff to use the money properly, and the fundamental basis on which health care is rationed has not been discussed. Staff (doctors and nurses) will remain disengaged, and regard this money as most likely to be wasted. Its like farting into a thunderstorm, or putting more money after bad. And of course in Wales this money will not all come to the health service, as a top slice will go to Welsh Government. How about starting by encouraging self care, and listing those services that all citizens should pay for? How about removing free prescriptions?

The Health Foundation: Does the NHS need more money and how could we pay for it?

This is the third of five briefings.

BBC News 5th August 20 NHS building projects given green light

Expert casts doubt on Johnson’s £1.8bn NHS funding promise
Financial Times5 Aug 2019

Boris Johnson insists £1.8bn pledged for NHS hospitals is new money The Guardian

Johnson’s £1.8bn for NHS will do little to fix crumbling hospitals
The Guardian5 Aug 2019

The Times3 Aug 2019
Image result for welsh NHS cartoon
…Sally Gainsbury, senior policy analyst at the health think tank the Nuffield Trust, said that £1bn of the investment was “not new money to NHS providers” as they had already earned it through incentive payments for cutting their costs but had had it held back by the Treasury. “It’s cash they already have in their accounts and will now be allowed to spend,” she tweeted.

The president of the Royal College of Physicians, Andrew Goddard, said, “While 20 more hospitals may seem a significant investment, it is unfortunately a drop in the ocean. Today’s announcement is certainly a small step in the right direction, but it’s a far cry from the great leap it will take to save our health service.”

“Having us all slim . . . would cost the NHS very much more money than the current level of topers, smokers and lardbuckets does.”

Aside from the fact that there is no NHS, this comment from Tim Worstall of the Adam Smith institute is honest and accurate. There is a cost to longevity, and we are currently unwilling to fund it as a nation. The result will be an unofficial two tier system. Quality, choice and speed for those who can afford it…… and only if we ration overtly can we redistribute funds and services in the interest of the majority, who will be subject to the opposite.

Image result for obesity epidemic cartoon

Matthew Moore reports in the Times August 6th: Let fat people die to save NHS money, says Michael Buerk

The state should leave obese people alone as their early deaths would save the NHS money in the long run, the BBC presenter Michael Buerk has said.

He said overweight people should be allowed to indulge if they wished, and that they were “weak, not ill”.

Buerk, 73, host of The Moral Maze on BBC Radio 4, suggested that over-eating might actually benefit society. “The obese will die a decade earlier than the rest of us,” he wrote in Radio Times. “See it as a selfless sacrifice in the fight against demographic imbalance, overpopulation and climate change.” He said that obesity should not be classed as a disease to encourage people to seek treatment, adding: “You’re fat because you eat too much.”

He also queried Public Health England’s claim that ill health related to being overweight or obese cost the NHS £6.1 billion a year.

“Who can calculate how much an obese person would have cost if they were slim?” he said……

..However, while Buerk’s claim may be couched in provocative language, there is scientific evidence to support him. In 2008 Dutch researchers found that up to age 56, obese people required the highest annual health expenditure but over the course of a lifetime healthy people were the costliest because they lived longer. Smokers were the “cheapest”, as they tended to die younger.

Tim Worstall, of the Adam Smith Institute, has called warnings that obesity poses an NHS funding crisis “nonsense on stilts”. He wrote: “When you add in the costs of the state pensions that those who die young don’t get, smoking and gorging save the government vast sums of money. Having us all slim . . . would cost the NHS very much more money than the current level of topers, smokers and lardbuckets does.”

Image result for obesity epidemic cartoon

A health crisis is a social crisis

When the pensions industry starts to make unanticipated profits, because it’s customers are dying earlier than predicted, you can rest assured they are pleased (financially!) but the last paragraph is worth repeating: A stalling or reversal of long term improvements in health and increases in health inequalities are of great concern to anyone who cares about health. They should also be a concern to anyone who cares about the society in which we live. Worsening inequalities in social conditions, worsening child poverty, cuts to services and, indeed, voting for Brexit or Trump, will all continue to make society worse. Health inequalities are telling us something fundamental about our society. And we must listen. see some of the headlines below.. These allude to some diseases on the rise, some with need for expensive screening and / or genetic treatments, and lack of access to primary care (those who find they cannot get through never seem to use the post for non-emergency care) especially for children.  As an aside, most of the litigation and the sexual misconduct applies to doctors from overseas. There’s a message here: stop rationing the training of doctors in the UK: go for overcapacity.. 

Michael Marmot opines in the BMJ editorial 24th May 2019 “A health crisis is a social crisis” ( BMJ 2019;365:l2278 )

Falling life expectancy and rising inequality are twin indicators of a society in trouble

Something is going badly wrong with society in the UK and the US. Is it linked to Brexit and Trump? Of course, but they are the consequence not the cause of problem—although they are wreaking their own havoc. A simple summary measure of the success of a society is its health: life expectancy has fallen in the US for three years in a row,1 and in the UK it has stalled since around 2011.2

When attention was first drawn to the slowing of life expectancy gains in England,34 concern was raised that it was not “real”—perhaps a severe winter was causing a short term fluctuation. That speculation is given the lie by the latest publication from the Office for National Statistics showing that life expectancy has stopped increasing in England and marginally declined between 2015 and 2017 among men and women in Scotland and Wales and among men in Northern Ireland.2 The pensions industry is in no doubt that the slowdown is real—it is making unanticipated profitsand the Institute of Actuaries has downgraded its core projection of cohort life expectancy at age 65.5

As a further indicator of societal ills, health inequalities are increasing in both the UK and the US. In women particularly, life expectancy has fallen in the most deprived areas of England—the more deprived the area, the steeper the decline.6 Inequalities in health derive from inequalities in society.7

Deaths of despair

Initially, the slowing of life expectancy in the UK seemed to come from a rise in mortality in older men and women. The US experience, by contrast, was marked by a rise in mortality in middle aged, non-Hispanic white men and women. The big contributors were deaths from unintentional poisonings, opioids, suicide, and alcohol. In case there was any doubt that this rise in mortality reflected important social trends, leading economists Case and Deaton labelled these as “deaths of despair.” 8 Mortality has also been rising among American Indians and Alaskan Natives and is now rising in African Americans—populations that already had higher mortality rates than white Americans.9

The UK may now be heading in the US direction. Deaths of despair are increasing, albeit on a smaller scale than in the US.15

These trends combined have led to a rise in mortality in young and middle aged adults.10 Alongside other rich countries, the UK rejoices in an infant mortality of three to four deaths per thousand live births. Even here, there is a worrying trend: between 2015 and 2016, infant mortality increased to nearly six per thousand deaths in the most deprived neighbourhoods, compared with a stable rate in the most affluent 10%.11

It is important not only to document these trends but to understand the underlying causes and to do something about them. In the US, deaths of despair follow the social gradient—the shorter the duration of education, the higher the rate. Case and Deaton speculate that cumulative disadvantage exacts a heavier toll on less educated people, with deteriorating job prospects, stalling incomes, social isolation, and relationship breakdown all contributing.

Effect of politics

In the UK, the fact that the break in the long term rise in life expectancy began in 2011 and has been accompanied by an increase in health inequalities must lead to serious questions about whether the government elected in 2010, with its flagship austerity policies, made a difference for the worse. It is difficult to answer such questions with precision, particularly since health inequalities arise over a lifetime of cumulative disadvantage.

Barr and colleagues entered this tricky domain with an evaluation of a government strategy to reduce health inequalities, implemented between 1997 and 2010.12 They examined the gap in life expectancy between the poorest 20% of areas in England and the rest and found that inequalities in life expectancy were increasing before the strategy, diminished during the strategy, and increased again when a new government came in with different policies. These researchers reached similar conclusions about infant mortality.13 Their results chime with analyses from the US of the long term downward trend in infant mortality from 1965 to 2010. When a Republican was in the White House the downward trend slowed a little; when it was a Democrat, the trend was a little faster.14

A stalling or reversal of long term improvements in health and increases in health inequalities are of great concern to anyone who cares about health. They should also be a concern to anyone who cares about the society in which we live. Worsening inequalities in social conditions, worsening child poverty, cuts to services and, indeed, voting for Brexit or Trump, will all continue to make society worse. Health inequalities are telling us something fundamental about our society. And we must listen.

Rosie Taylor in the Times 12th July 2019: A third of callers can’t get through to their GP surgery

The Express and Star 22nd July 2019: Hospital admissions for sepsis more than double in 3 years

The Times 22nd July 2019:Steep rise in young people suffering from bowel cancer

The Mail 13th July 2019: Foreign doctors are revealed to be behind 60% of all sex assaults on …

 

 

The firm: does it hold the answers to teamworking and morale?

I very much regret that I cannot attend my 50 year medical school reunion. The memories of the “teams” and the convivial mess atmosphere, the mutual recognition of the brutalisation and stress, and the joint need to cover each other were the icing on the cake of a wonderful time. Morale was high. The “cause of all the mahem” is only partly in the article, and an explanation is in the replies.

I remember playing hockey in a team regularly because I had a colleague who played international squash. Our games did not coincide, and so we were able to cover each other despite being on a one in two rota.

I never had to miss a wedding, because there was always a volunteer to do an on call swap.

The mentoring was continuous and the feedback immediate..

Nowadays young doctors are afraid to tell anyone, colleagues or management, that they would like to get married in 6 months time, or to move house in 2 weeks time. 

There is an unwritten rule in medical training: the larger the firm the less willing anyone is to make swaps in their rota. Perverse in that there is more opportunity to trade…

Of course there are many more part time trainees, especially in speciality training and General Practice, and these doctors have children and commitments, but NHSreality regards these as excuses rather than reasons. With a one in two rota the gain was large enough to tempt both parties…..

Abi Rimmer opines in the BMJ. The firm: does it hold the answers to teamworking and morale? (BMJ 2019;365:l4105 )

Rotations and shift patterns mean that junior doctors often struggle to feel part of a team. Some want to bring back the “firm” way of working. But is this feasible, and was the firm really part of a golden age for trainees, asks Abi Rimmer

In the discontinued “firm” system—a model of medical apprenticeship—groups of doctors worked together to provide patient care.

Firms generally had at least one permanent member, a consultant, who led the firm and after whom it was named. Some four of five trainees of varying seniority weren’t permanent members of this firm, but they belonged to it, and for many it was a consistent source of professional and emotional support.1 The quality of education and training that trainees received, however, varied.2

The firm’s demise came after 2005 when trainees began rotating more frequently under the Modernising Medical Careers programme. From 2009 European working time regulations shortened doctors’ working hours. Junior doctors spent less time on the wards and their involvement in teams became far more transitory.

But many doctors would like to see the firm reinstated, seeing it as an answer to today’s problems of disenfranchisement and low morale among junior staff.

The cause of all the mayhem

When the firm functioned well, says the Royal College of Physicians (RCP), it provided “a structured development process, role modelling of professional behaviour, mentoring, and a good balance of challenge and support.”2

Harold Ellis, a retired professor of surgery who qualified in 1948, describes his firm as being like a family. In a firm, Ellis tells The BMJ, there would be one or two consultants known as “the chiefs,” a senior trainee known as “the registrar,” a junior trainee known as the “house physician” or “house surgeon” who lived in the hospital, and medical students.

“The firms were wonderful,” he says. “A lot of people think that the breakup of the firm is one of the causes of all the mayhem in the health service now.”

In 2016 junior doctors throughout England took industrial action over contract changes, and the then health secretary Jeremy Hunt expressed regret at the loss of the firm.

By dismantling the system, Hunt said, “We may have thrown the baby out with the bathwater. Can we bring back the firm or at least the best bits of it?”3 Also in 2016, research from the RCP concluded that the fragmentation of medical teams from frequent junior doctor rotations, rota gaps, and limited induction was central to trainees’ disengagement.4

An answer to junior doctors’ wellbeing?

Junior doctors’ displeasure about their contract and working conditions has pushed their wellbeing up the agenda.5 And the narrative persists that the firm provided yesterday’s medical trainees with something that is missing today.

In a recent letter to The BMJ, the locum Niak-Puei Koh lamented the loss of the firm as “a key cause of disconnect between junior and senior staff, where the feeling of being unsupported seems to be rampant.”6

He added, “The loss of the doctors’ mess, the sitting room for nursing staff, and a specific canteen (away from the public eye) have eroded this sense of community. Bringing some of these back—and even enabling teams to sit down with a cup of tea to discuss the daily chores—might foster a better working relationship and help team members feel less isolated.”

The anaesthetic registrar Joanna Poole laments the lack of a supportive team structure in medicine. “I love medicine, and my colleagues are smart, funny, caring, and inspiring,” she wrote. “But none of my seniors, who I get on well with, knew about my engagement or the death of my dad and my grandad, either because of the rota pattern, busy shifts, or we aren’t designed to ask. We all get asked how our shifts were but not the viscera of our lives.

“In the old days you had a firm or ability to socialise outside of work. We rotate so far geographically now this is difficult. Longer placements would be more humane, with secondment for tertiary specialties,” she said.7

Ellis is not surprised that today’s trainees are struggling. “Eleven hour shifts without a break is inhuman,” he says. Although he worked very long hours as a trainee in the late 1940s and ’50s, the work was less intense and he lived on site.

“If things were quiet you would take some time off: you could go and sit in the garden or pop out to get your hair cut,” he says. “There’s nowhere now for trainees to sit down and read the newspaper and have a cup of tea. We had our own mess but that’s been taken away.”

Without the close team working of the firm, Ellis says, consultants can no longer judge their trainees’ skills or learning needs. “My boss would say, ‘Come on Harold, you’ve seen me do this 10 times. Swap round: you stitch him up, and I’ll cut the knots for you,’” he says.

Autonomy within boundaries

James Morrow, a Cambridge GP, says that the firm built trust that gave trainees more freedom to learn.

“You were given a great deal of autonomy—within boundaries,” he says. “You could push yourself to achieve new things, knowing that there was support, in a non-judgmental way, available from someone who viewed you as part of the core team. And that is incredibly powerful.”

The firm also gave trainees a feeling of stability because they knew who they would be working with, Morrow says. “You looked out for each other, and backed each other up.”

However, the firm also came with disadvantages, Morrow remembers. “Some of the worst times of my life, as well as some of the best times, were working on a firm. The unrealistic expectations to be there all the time, to know everything, were not conducive to a happy life outside the hospital ward,” he says.

“We have improved working hours to a large extent, and that should be retained,” he says, but he’d like to see “if we can bring back some of the magic that made being junior doctor such great fun” by “working as part of a consistent, coherent, collective team.”

Health Education England (HEE) wants to do just that, Sheona Macleod, deputy medical director for education reform, told The BMJ.

Bringing back the best

“It’s not possible to bring the firm back the way it was but HEE is asking, ‘What was good about the firm? What do people miss about it? And how do we provide these things in the current training and working environment?’” she says.

As well as helping to establish a programme to improve surgical training (box 1), HEE has helped to fund guidance from the RCP on how today’s teams can learn together and support each other (box 2).

Box 1

Could a modern firm improve surgical training?

In 2016, Jeremy Hunt announced that Health Education England would work with the Royal College of Surgeons, teaching hospitals, and education providers to explore whether a modern firm structure could improve team working and make junior doctors feel more valued.3

The college started recruitment to the Improving Surgical Training (IST) pilot scheme throughout England, Scotland, and Wales in 2017. At the time Ian Eardley, senior vice president of the college, explained that the modern firm would omit the long hours and frequent on-calls but would re-create the best aspects of the old model.

He said, “The nice things about the firm were that you had a support structure in place; if you had a problem, no matter what hour of the day or night, you always had a person who you knew could help you, who could give you some advice.”8

In August 2017, 48 general surgery trainees in England and 31 core surgical trainees in Scotland took up their posts in the pilot.

Daniel Beral is a consultant colorectal and general surgeon and trainer on the IST programme who is involved in training the trainers in the pilot.

Trainees taking part have longer placements, of up to 12 months, which he hopes will foster stronger relationships with their consultants.

This relationship is key, and the scheme promotes regular meetings between trainees and supervisors. “In the firm structure you often worked for one, two, or three consultants but somebody actually got to know you,” Beral says.

The pilot focuses on the whole clinical team. “In some of the sites, newer team members such as surgical care practitioners or advanced care practitioners contribute to the on-call rota,” Beral says. “This means that there are more people on the rota and the trainees can work more in daylight hours.”

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Feature Medical Training

The firm: does it hold the answers to teamworking and morale?

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4105 (Published 10 June 2019) Cite this as: BMJ 2019;365:l4105

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  1. Abi Rimmer

Author affiliations


  1. The BMJ

Rotations and shift patterns mean that junior doctors often struggle to feel part of a team. Some want to bring back the “firm” way of working. But is this feasible, and was the firm really part of a golden age for trainees, asks Abi Rimmer

In the discontinued “firm” system—a model of medical apprenticeship—groups of doctors worked together to provide patient care.

Firms generally had at least one permanent member, a consultant, who led the firm and after whom it was named. Some four of five trainees of varying seniority weren’t permanent members of this firm, but they belonged to it, and for many it was a consistent source of professional and emotional support.1 The quality of education and training that trainees received, however, varied.2

The firm’s demise came after 2005 when trainees began rotating more frequently under the Modernising Medical Careers programme. From 2009 European working time regulations shortened doctors’ working hours. Junior doctors spent less time on the wards and their involvement in teams became far more transitory.

But many doctors would like to see the firm reinstated, seeing it as an answer to today’s problems of disenfranchisement and low morale among junior staff.

The cause of all the mayhem

When the firm functioned well, says the Royal College of Physicians (RCP), it provided “a structured development process, role modelling of professional behaviour, mentoring, and a good balance of challenge and support.”2

Harold Ellis, a retired professor of surgery who qualified in 1948, describes his firm as being like a family. In a firm, Ellis tells The BMJ, there would be one or two consultants known as “the chiefs,” a senior trainee known as “the registrar,” a junior trainee known as the “house physician” or “house surgeon” who lived in the hospital, and medical students.

“The firms were wonderful,” he says. “A lot of people think that the breakup of the firm is one of the causes of all the mayhem in the health service now.”

In 2016 junior doctors throughout England took industrial action over contract changes, and the then health secretary Jeremy Hunt expressed regret at the loss of the firm.

By dismantling the system, Hunt said, “We may have thrown the baby out with the bathwater. Can we bring back the firm or at least the best bits of it?”3 Also in 2016, research from the RCP concluded that the fragmentation of medical teams from frequent junior doctor rotations, rota gaps, and limited induction was central to trainees’ disengagement.4

An answer to junior doctors’ wellbeing?

Junior doctors’ displeasure about their contract and working conditions has pushed their wellbeing up the agenda.5 And the narrative persists that the firm provided yesterday’s medical trainees with something that is missing today.

In a recent letter to The BMJ, the locum Niak-Puei Koh lamented the loss of the firm as “a key cause of disconnect between junior and senior staff, where the feeling of being unsupported seems to be rampant.”6

He added, “The loss of the doctors’ mess, the sitting room for nursing staff, and a specific canteen (away from the public eye) have eroded this sense of community. Bringing some of these back—and even enabling teams to sit down with a cup of tea to discuss the daily chores—might foster a better working relationship and help team members feel less isolated.”

The anaesthetic registrar Joanna Poole laments the lack of a supportive team structure in medicine. “I love medicine, and my colleagues are smart, funny, caring, and inspiring,” she wrote. “But none of my seniors, who I get on well with, knew about my engagement or the death of my dad and my grandad, either because of the rota pattern, busy shifts, or we aren’t designed to ask. We all get asked how our shifts were but not the viscera of our lives.

“In the old days you had a firm or ability to socialise outside of work. We rotate so far geographically now this is difficult. Longer placements would be more humane, with secondment for tertiary specialties,” she said.7

Ellis is not surprised that today’s trainees are struggling. “Eleven hour shifts without a break is inhuman,” he says. Although he worked very long hours as a trainee in the late 1940s and ’50s, the work was less intense and he lived on site.

“If things were quiet you would take some time off: you could go and sit in the garden or pop out to get your hair cut,” he says. “There’s nowhere now for trainees to sit down and read the newspaper and have a cup of tea. We had our own mess but that’s been taken away.”

Without the close team working of the firm, Ellis says, consultants can no longer judge their trainees’ skills or learning needs. “My boss would say, ‘Come on Harold, you’ve seen me do this 10 times. Swap round: you stitch him up, and I’ll cut the knots for you,’” he says.

Autonomy within boundaries

James Morrow, a Cambridge GP, says that the firm built trust that gave trainees more freedom to learn.

“You were given a great deal of autonomy—within boundaries,” he says. “You could push yourself to achieve new things, knowing that there was support, in a non-judgmental way, available from someone who viewed you as part of the core team. And that is incredibly powerful.”

The firm also gave trainees a feeling of stability because they knew who they would be working with, Morrow says. “You looked out for each other, and backed each other up.”

However, the firm also came with disadvantages, Morrow remembers. “Some of the worst times of my life, as well as some of the best times, were working on a firm. The unrealistic expectations to be there all the time, to know everything, were not conducive to a happy life outside the hospital ward,” he says.

“We have improved working hours to a large extent, and that should be retained,” he says, but he’d like to see “if we can bring back some of the magic that made being junior doctor such great fun” by “working as part of a consistent, coherent, collective team.”

Health Education England (HEE) wants to do just that, Sheona Macleod, deputy medical director for education reform, told The BMJ.

Bringing back the best

“It’s not possible to bring the firm back the way it was but HEE is asking, ‘What was good about the firm? What do people miss about it? And how do we provide these things in the current training and working environment?’” she says.

As well as helping to establish a programme to improve surgical training (box 1), HEE has helped to fund guidance from the RCP on how today’s teams can learn together and support each other (box 2).

Box 1

Could a modern firm improve surgical training?

In 2016, Jeremy Hunt announced that Health Education England would work with the Royal College of Surgeons, teaching hospitals, and education providers to explore whether a modern firm structure could improve team working and make junior doctors feel more valued.3

The college started recruitment to the Improving Surgical Training (IST) pilot scheme throughout England, Scotland, and Wales in 2017. At the time Ian Eardley, senior vice president of the college, explained that the modern firm would omit the long hours and frequent on-calls but would re-create the best aspects of the old model.

He said, “The nice things about the firm were that you had a support structure in place; if you had a problem, no matter what hour of the day or night, you always had a person who you knew could help you, who could give you some advice.”8

In August 2017, 48 general surgery trainees in England and 31 core surgical trainees in Scotland took up their posts in the pilot.

Daniel Beral is a consultant colorectal and general surgeon and trainer on the IST programme who is involved in training the trainers in the pilot.

Trainees taking part have longer placements, of up to 12 months, which he hopes will foster stronger relationships with their consultants.

This relationship is key, and the scheme promotes regular meetings between trainees and supervisors. “In the firm structure you often worked for one, two, or three consultants but somebody actually got to know you,” Beral says.

The pilot focuses on the whole clinical team. “In some of the sites, newer team members such as surgical care practitioners or advanced care practitioners contribute to the on-call rota,” Beral says. “This means that there are more people on the rota and the trainees can work more in daylight hours.”

RETURN TO TEXT

Box 2

Maximising learning in the modern workplace

In its Never Too Busy to Learn guidance the Royal College of Physicians sets out how doctors working in modern teams can find the same kind of education and peer support that the firm offered.2

Medicine and patient care have changed substantially since the days of the firm, says Emma Vaux, senior censor at the college and one of the authors of the guidance.

“The team is no longer just doctors. As many as 18 different professionals look after a patient on a medical ward, and they are all contributing something,” she tells The BMJ. “We are working together, so why can’t we learn together?”

The guidance aims to look at “how we can capture the essence of what was really good about the medical firm,” she says, but without rose tinted glasses.

Recommendations from Never Too Busy to Learn for creating and maximising learning opportunities in the modern workplace are:

  • 1 Target your time—make inter-professional board rounds more efficient

  • 2 Use brief learning moments—take a break in the day to teach and have a cup of tea

  • 3 Learn while with patients—make ward rounds and outpatient clinics educational

  • 4 Learn by caring—listen to the experiences and emotions of staff

  • 5 Practice makes progress—integrate simulation into the working day

  • 6 Share professional experiences—role modelling and mentoring can support learning

  • 7 Share learning experiences—use quality improvement projects and grand rounds to increase learning

  • 8 Embrace technology—consider how it can improve doctors’ education

  • The guidance recognises some of the advantages of the firm but also that learning was “inevitably variable, accounting for considerable inconsistency in educational quality and outcomes for trainees, and in the resultant standards of patient care.”2

    But it also gave consultants time to give trainees individualised careers advice, Macleod says. In its ongoing review of foundation training, HEE will “recommend that foundation doctors should have non-clinical training so that they can think about different career options,” Macleod says.

    Other HEE projects have re-created other positive aspects of the firm. “In the past, your consultant might have suggested that you do research, or follow up on something,” Macleod says. “The flexible portfolio careers work we are doing in Enhancing Junior Doctors’ Working Lives allows people to pursue an interest while they are working.”

    Macleod also recognises that not everyone had good experiences of the firm and some people’s careers were cut short by bullying. “It’s not an easy story to tell, ‘I was going to be a surgeon but this man in my firm made fun of me for six months so I gave up and became something else.’”

    Jeeves Wijesuriya, chair of the BMA Junior Doctors Committee, says that nostalgia for the firm often ignores that when it operated lots of other things worked differently too. “There was less regulation, less oversight and measurement of performance, for example,” he says.

    However, through the ongoing work that the BMA is doing with the government to improve the 2016 junior doctors’ contract, Wijesuriya is hoping that some of the positive aspects of the firm can be brought back.

    For example, he is hopeful that improved job planning for trainees will give them greater autonomy over their work schedules and more quality time with their educational supervisors.

    “At the nub of it is community and a relationship with your boss. The feeling that your educational supervisor isn’t just ticking off the required items without ever taking an interest in you,” Wijesuriya says.

    “What we are trying to develop for junior doctors is relationships with supervisors who are interested in their career and in what they want to do next. That will not just keep trainees in the profession but will also bring the profession together.”

Closure of many more surgeries…. And there’s an epidemic of dementia coming….

Popular cities like Bristol do not expect to be without GP cover. There have been many more since I last posted on GP closures. The Headline generated by Amanda Cameron in Bristol Live 2nd August reads: 

Health chiefs explain decision to close two GP surgeries in Bristol – The decision left 15,000 patients needing to sign up with another surgery within three months

The shortage of GPs is one thing, due to retirement, career changes, part time, and emigration (as well as early retirement due to stress and overwork), but the fact that we have a wave of demented patients coming in the next few years has not become real to the politicians. And it is not just doctors who are under stress. Midwives and nurses too… After all they will be up for re-election before that time, and may not win. The same explanation applies to the inertia om medical recruitment, acknowledgement of dementia, climate change and several other areas….. A first past the post system means we are all subject to short termism. Mending the 4 health services will take decades. So will addressing climate change… The pace of technology advance, especially following CRISPR, is faster than any government can afford. There is only one solution and that is to ration health care, with co-payments according to means. A quality service needs to have equal opportunity for all, and whilst “extras” such as private rooms or choice of specialist are reasonable in a two tier system, different outcomes and life expectancies are not. Will new tests (such as that for dementia) be available to all? In the end it is caring, continuity and trust  that matter rather than technology, especially when we are old.

You may wonder “Perhaps a new health secretary will change things”. No chance.

Scream, Jeremy Hunt, NHS, cartoon

“..Announcing the closure, the CCG said supporting patients to transfer to a neighbouring practice was the “best long-term solution”.

At a meeting of its primary care commissioning committee on July 30, it emerged that the CCG considered three options before deciding to close the Bishopston and Northville surgeries.

Those options included keeping both surgeries open, merging them with other practices, or closing them and sending patients elsewhere.

Following extensive consultation with patients, the CCG concluded that closing them would have “on balance, a neutral impact” on most patients.

Patients might also benefit from “improved provision of care” from practices offering a wider range of services, CCG papers show…..”

Owain Clarke for BBC News 31st July 2019: Cwm Taf maternity crisis: Midwife stress adds to staff problems

Rhys Blakely on June 13th reports in the Times: NHS creaking under the strain of record dementia diagnoses

The head of the NHS dementia strategy has warned that the service is struggling to keep up as cases of the degenerative condition surge.

NHS figures released yesterday showed that nearly 454,000 people aged 65 or over in England have formally had dementia diagnosed: a record. The number of diagnoses has increased by 7 per cent in the past three years…… Alistair Burns, the NHS national clinical director for dementia, said: “The NHS is having to run to keep up as dementia becomes a challenge for more and more families.”

BBC news today: Alzheimer’s blood test ‘one step closer’ ( By testing for amyloid )

Researchers say they can accurately identify people on track to develop Alzheimer’s disease before symptoms appear, which could help the progress of drug trials.

US scientists were able to use levels of a protein in the blood to help predict its build-up in the brain.

UK experts said the results were promising – and a step towards a reliable blood test for Alzheimer’s to speed up dementia research.

My own advanced directive. A timely death is a choice everyone can make for themselves.

A doctors own personal choice is not usually talked about, but more and more are doing their own advanced care pans, which used to be called a living will. Here is mine: Final ADRT DR RB. The media led society does not sustain debate about the way we die, and charities such as our local Hospice at Home in Pembrokeshire, are reluctant to advertise a service for fear of being accused of bullying patients, and of being in collusion with the local health board. After all, the state has an interest in shorter periods of dying because of the expense.

My previous “Living Will” is out of date. Readers are welcome to copy and adapt the one above. I am most grateful for the free service, and recommend it to others. Just contact the Paul Sartori Foundation if you live in Pembrokeshire.

At present we are prolonging death. The care and nursing homes are taught to sit patients up, Death comes much sooner when patients lie flat. There is no need for pain with modern drugs, but we are moving to a world where a timely death is a choice everyone can make for themselves.

In a briefing paper in 1997 the government of the day was advised on the options for Social Care funding. No action has been taken. Social care: Government reviews and policy proposals for paying for care since 1997 (England) by Tim Jarrett. We are in a terrible mess as standards are different in different dispensations, and this report applied only to England.

It does seem ironic that, in a system that we all know is rationed (Politicians all deny this), that so many resources (state or private) are given to prolonging death.

Image result for living will cartoon

Live longer with dementia: Mr Hunt pillories the profession. Most doctors will be making “living wills” to avoid over-zealous care and prolonged demented lives… March 7 2016

An advanced directive or living will – It’s important to specify, especially lying flat. Good news if you take action.April 14th 2014

Health postcode lottery: The Mirror’s online tool shows how many years of illness you can expect – but only for those living in England….21st November 2015

Living through the NHS’s famine years. Quality reversals and increasing deficit November 7th 2014

s are symptomatic of deeper problems

Late cancer diagnosis… and poor cancer care. Let GPs have access to tests, and when there are enough, involve them in key treatment decisions.

The neurosurgeon Henry Marsh on why assisted dying should be legalised

Suicide clinics a preserve of middle class A report says only sharp-elbowed Britons are able to access assisted dying at Swiss centres

Families asked to feed dementia patients…. How do we design a system that is fair to both the well spread, and the very locally based families?

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

Don’t get old and frail – if you can avoid it – in our covertly post-code rationed services