Category Archives: Medical Education

We are still not training enough doctors, and the gender and undergraduate bias needs to be changed.

So there are more applicants for medical school. We need (at least) 5000 more (Per annum) and we are training an extra 900 per annum. With part time and early retirement we are still going to run out of doctors.… Virtual Medical schools would be a great help… Graduate entry only would be even better… And then there’s the debt..

In the Times today 7th November Rosemary Bennett reports: Fight for Oxbridge place tougher than ever after applications surge

…..More want to take medicine
Applications to study at medical schools have risen by 6 per cent compared with last year. There were 23,710 applications to medical schools for courses that had an early deadline of October 15. Of those, 18,500 came from prospective doctors within Britain, an increase of 5 per cent. The rise in interest to become a doctor comes after five new medical schools opened their doors within the past year. These include schools at the universities of Sunderland, Lincoln and Edge Hill, in Ormskirk, Lancashire. Other long-established medical schools have increased the number of places available.

Some good news on new medical schools. Lets hope the politicians sieze the real opportunity for virtual medical schools living in local communities

Its more than a thin front line, as half timers take over from deserters…

There’s a horrible smell around the Health Service(s) battlefield: it’s more than an “ill wind”.

After promising to clone GPs, and failing, Mr Hunt promises to “make” more radiologists… Importing them will block our own for years. Exporting films abroad is an option…

NHS needs 5,000 trainee doctors a year…..!

fewer women should be allowed to train as doctors because men are ‘better value for money’… The answer is graduate entry to medical school.

Health Services might be designed wrongly: In praise of dissenters.. Currently there is little ability to speak out, “without fear of sanction”.

The Different health services in the UK are not open to the suggestion that they might be designed wrongly. They are failing more quickly than anyone imagined (other than those in the profession, and NHSreality). An interview with Helen Stokes-Lampard (RCGP chair) In “You and Yours” on Radio 4 17th October 2019 tells it straight: its going to take at least 12 years to remedy the failure in forward and manpower planning. (The interview is at the end of the recording) The culture of fear means that opportunities to learn constructively are being lost, educational standard are falling, and engagement with the politics of health is minimal. One route to honesty is the exit interview, and these collated together could give messages that lead to the changes needed. Meanwhile……  “Winter is coming”. We will all be hearing how they will listen (See Jill Patterson in Walesonline below), but NHSreality can tell you that even if they hear, they don’t have the human resources to act. 

In Bartleby in The Economist 12th October 2019 “In praise of dissenters – It pays companies to encourage a variety of opinions “

The ability to speak up within an organisation, without fear of sanction, is known as “psychological safety” and was described by Amy Edmondson of the Harvard Business School in a book on the issue. Mr Syed cites a study of teams at Google, which found that self-reported psychological safety was by far the most important factor behind successful teamwork at the technology giant. ….“In praise of dissenters

As many practices disintegrate, I give a link to a local practice in the news.

Eleanor Philpotts in Pulse 12th October 2019 reports on Ferryside practice.: Practice set to close after 3 years without a GP

In Walesonline Sandra Hembury on 14th October reports: The GP surgery that hasn’t had a GP for over 3 years..

A doctors’ surgery hasn’t had a GP working there for three years and is now being threatened with closure.

The Mariners Surgery in Ferryside has only had nurse sessions since 2016, because there were no GPs available to operate from it.

Now plans have been unveiled to close the surgery and relocate services to other practices, forcing patients to have to travel for miles to receive treatment.

A public drop-in session is being held to consult with patients at the Three Rivers Hotel in Ferryside between 2pm and 7pm tomorrow (Tuesday, October 15).

But there are fears those less mobile patients will struggle to get to the next nearest surgeries in the Meddygfa Minafon practice – in Kidwelly or Trimsaran.

Cllr Mair Stephens is ward councillor for St Ishmael and deputy leader of Carmarthenshire County Council.

She said the Carmarthen Road practice had been there for a number of years.

“There’s traditionally been a dispensing surgery, which is exactly what we do need,” she said.

“The majority of people who live in the area are older, and the surgery has been on the decline in recent years, but it still has such things as foot clinics and heart clinics.

“They are now going to close it, which is out of all proportion.”

She said the nearest surgery in the group was Minafon in Kidwelly, which was about four miles away. But it was difficult to get to if patients needed public transport. The nearest bus route to the Kidwelly surgery dropped passengers off at least 10 minutes away from the practice, which wasn’t suitable for the less mobile, she added.

She suggested the practice could set up a bus route taking passengers without suitable transport from the Ferryside surgery to Kidwelly.

Cllr Stephens added: “This is about moving services from their locality.

“What older people want to do is to see a GP. They don’t necessarily want to see a nurse.

“Once they have seen the doctor they are quite happy to meet a nurse or practitioner. That’s where the whole system seems to be falling down.”

She felt the consultation was not being spread out enough to the wider community, including nearby Llandyfaelog.

A petition has been set up to maintain the surgery in Ferryside.

Started by Ute Eden, it says: “We feel very strongly that it is essential to maintain a surgery in Ferryside.

“We need a doctor, a nurse and a dispensary to provide the vital services required by a village where most residents are over the age of 50.

“It is an integral part of Calon y Fferi Community Centre, which is very accessible.”

The petition, which has been signed by 44 people, said it would be a backward step to oblige all residents to leave the village for treatment.

Jill Paterson, director of primary care at Hywel Dda University Health Board, said: “As a health board we are committed to listening to and engaging with local populations around our proposals to relocate our primary care services from Mariners Surgery to neighbouring surgeries.

“We would therefore like to invite residents to come along and get involved in the conversation.

“Following a review of how services are used by patients at the surgery, it is becoming clear that these services are limited and not fully utilised and could be relocated to Minafon and Trimsaran Surgeries.”

A&E standards fall – the end game means an opportunity for private A&E and Ambulance services in richer areas

Don’t wait until you are ill, or your next of kin needs emergency care. Try and think ahead to what options you have in your post code. In reality most of us will have no choice, but there may be a choice in the bigger cities. Certainly NHSreality expects market forces to mean private services expand. As A&E standards fall – the end game means an opportunity for private A&E and Ambulance services in richer areas. And its going to get worse…

It is all very well having long waits for access to GP and cold hospital care, but it is quite another when one of the holes in the safety net gets so large that the net has been removed. I can attest to the fall in standards from personal experience with a recent Right hand compartment syndrome that was ignored at first, and then operation was delayed, for a total of 18 hours. The recovery will be longer, and more painful than it might have been, but thank goodness I have kept my hand.

The failure in manpower and forward planning in general, the over supply of doctors who wish to work part time, and under supply of those who wish to work full time, rationing of medical school places, and lack of increased reward for working a shift pattern career are all part of the problem. There is no valuing of what are seen as temporary staff, and it has to get worse…

The Care Quality Commission

Henry Bodkin in the Telegraph 15th October: More than half A&E services failing

More than half of A&Es are now failing because patients who should be treated at home or in clinics are flooding through emergency departments’ “ever-open doors”, inspectors have warned.

The Care Quality Commission said breakdowns in provision for dementia and mental health patients are fueling the deterioration of standards….

ITV News: A&E under tremendous pressure as more departments need improvement (Standards fall)

Shaun Lintern in Health Service Journal: Regulator warns of ‘extraordinary’ winter for A&Es

  • Chief inspector warns of “extraordinary circumstances” for emergency departments this winter
  • Care model failure leaves hospitals overloaded
  • Watchdog warns of deterioration on mental health, learning disability and autism wards

A failure to provide the right models of care is forcing thousands more people to attend emergency departments each day, the Care Quality Commission has said, while warning of a “perfect storm” for the health service this winter……

Dennis Campbell in the Guardian: More than half of A&Es provide substandard care, says watchdog – Hospitals struggling to cope with rising numbers of patients who cannot get help elsewhere

Kaya Burgess in the Times: More than half of A&Es not up to job, says care watchdog

The health watchdog has warned that A&E departments are under “tremendous pressure”, with more than half now deemed inadequate or in need of improvement.

The Care Quality Commission’s annual State of Care ( England only) report also warned of a “perfect storm” across health and social care where people cannot access the services they need or where care is provided too late.

The regulator found that A&E standards had slipped over the past year and that emergency departments were the most likely part of a hospital to be ranked as inadequate.

In 2018-19, 44 per cent of urgent and emergency services were rated as requiring improvement — up from 41 per cent the year before — with a further 8 per cent deemed inadequate, up from 7 per cent the year before.

Inspectors said that A&E departments had not had their usual “breathing space” over the summer months to prepare for the perennial winter pressures.

He said: “We know that it’s a combination of increased demand and challenges around workforce [that] are creating something of a perfect storm and if that perfect storm is allowed to continue we will have a number of problems.”

He said that the 18-week waiting list for planned hospital treatment had grown from about 3 million people to 4.4 million over the past five years.

The CQC also warned of a “serious deterioration” in the quality of inpatient services for people with mental health problems, autism or learning disabilities. About 7 per cent of child and adolescent mental health services were rated inadequate last year, up from 3 per cent the year before.

Mr Trenholm said: “We also know that adult social care remains fragile. We know that the failure to agree a long-term funding solution is driving instability in the sector.”

Sally Warren, director of policy at the King’s Fund health charity, said: “The CQC’s report provides further evidence that staffing is the make-or-break issue across the NHS and social care. Staff are working under enormous strain as services struggle to recruit, train and retain enough staff with the necessary skills.”

Nick Scriven from the Society for Acute Medicine said: “At some point in the near future all these sustained and repeated problems with increasing demand, inadequate workforce that is haemorrhaging senior cover, the pension tax crisis, crumbling estates, insufficient community medical care and community social care in general totally under-provisioned, we will reach a vital tipping point and care will be compromised despite all the heroic efforts by the human side of this, the staff in post.”

An NHS spokesman welcomed the watchdog’s finding that quality standards had remained stable when taken as a whole and said: “While the NHS Long Term Plan set out an extra £4.5 billion to ramp up GP and community care, the CQC rightly highlights the need for a long-term solution to adult social care so that older and vulnerable people get the right care when they need it.”

March 2015 NHSreality: From bad to worse: “NHS medical accidents investigation unit ‘needed’”

Jan 2016 NHSreality: Accident and Emergency – departments understaffed – report suppressed

Doctors let dying patients waste their last days in Accident and Emergency

The Care Quality commission has different standards and reports in different jurisdictions

 

Diversity in training is good, but “Dumbing down medical schools could be lethal”, unless exams are discriminateory.

In a letter to the Times published 11th August in response to an article on easing admission criteria to medical school, Dr Simon Rose points out the risks in lowering standards. those of us who have been through the brutality of medical training, house jobs and specialist training know that although a certain basic intelligence certainly helps, it is determination, stickability, bloody mindedness and long term planning that get one through, and the grades at admission bear no relation to whether the doctor becomes a specialist, a professor or a GP. We do not want standards to fall, but there are exams in medical school, and with these and final exams it should be possible to weed out those who might become “lethal”.

What really would help is graduate as opposed to undergraduate entry, as this would equalise the sexes, and to aim at overcapacity. Staff who feel valued make fewer lethal mistakes, so this too needs addressing..

Letters to the Editor: Dumbing down medical schools could be lethal

Sian Griffiths had reported 4th August in the Times: Medical schools ease admission rules in name of diversity

Top universities are dropping some of the hardest A-levels from their entry requirements to attract more girls and poorer pupils on to courses dominated by male and middle-class students.

Physics is no longer an A-level prerequisite for some engineering degrees, or chemistry for some courses to study medicine.

The move was condemned this weekend as “social engineering gone mad” by one expert who said it could lead to engineers building dangerous bridges and doctors missing diagnoses.

Bristol University said it hoped its decision to stop insisting that applicants to its main engineering course had A-level physics would “increase the diversity of students”. Civil engineering courses at University College London and some at Southampton no longer require A-level physics either.

Only about 20% of A-level physics entries are from girls, and research suggests it is the hardest subject in which to get a top grade.

Medical schools are also changing their entry requirements in an attempt to break the stranglehold of affluent and privately educated students.

At Manchester University, those studying medicine no longer have to have chemistry A-level, a prerequisite for decades. Psychology is accepted as a science subject.

Drew Tarmey, head of medical school admissions at Manchester, said selection tests and interviews could help selectors to spot the best candidates when more liberal entry requirements came in. He said: “As far as subject requirements go, we are thinking, ‘Where do we go from here? Does somebody have to have two sciences? Would biology, history and French, for instance, be any different?’”

From 2020 Norwich Medical School, part of the University of East Anglia (UEA), will not require applicants to have A-level chemistry. Neither will new medical schools at Sunderland University and Anglia Ruskin, in Chelmsford.

Chris McGovern, chairman of the Campaign for Real Education, said: “If bridges start falling down or diseases are missed because the students were not properly prepared, we will all suffer. This is social engineering gone mad.”

Dr David Barton, engineering admissions officer at Bristol, said parts of A-level physics had been incorporated into first-year courses to plug any gaps.

Alix Delany, UEA’s head of admissions, said: “Allowing students studying either biology or chemistry for A-level to apply for medicine gives us the opportunity to interview a wider variety of prospective students, where we want to see them demonstrate their caring and empathetic attitude, which is a quality that is just as important to us as academic ability.”

Dr Simon Rose letter: 

The head of admissions at the University of East Anglia says that for prospective medical students, a “caring and empathetic attitude” is as much a qualification as academic ability (“Medical schools ease admission rules in name of diversity”, News, last week). This is shocking.

If I am an unconscious patient on a respirator in intensive care, with complex ventilatory requirements, renal failure and disordered blood chemistry, I need someone able quickly to apply academic rigour and scientific knowledge to stabilise my condition.

Doctors selected for empathy, but not so good at chemistry, may be better at telling my children that I have died, but that might not have been necessary had they met the entry requirements at a more rigorous university.
Dr Simon Rose, Bath

The Nuffield Trust – Workforce conclusions. The overseas doctors we import will doubtless block the opportunities for our own in 1o years time… if we do train enough.

The Nuffield Trust admits that it has not addressed geographical considerations, but this is addressed by overcapacity. The fact that even this year only one in 10 applicants to medical school is successful speaks volumes. We need virtual medical schools, adverse selection so that rural and poverty stricken areas are allocated a fair share of doctors to train, and a “tie in” whereby doctors can be induced to stay where they are most needed. The overseas doctors we import will doubtless block the opportunities for our own in 1o years time… if we do train enough.

In Action for health: key areas for action in the health and social care workforce (21st March 2019), the Nuffield Trust summarises in Next Step and Conclusions:

The NHS Long-Term Plan recognises that over the past decade workforce growth has not kept up with the demands on the service and that the NHS now needs a comprehensive workforce plan to tackle staffing shortages, improve working lives and better utilise the talents and skills of the million plus people who work in the health service. Few disagree that the workforce is the make-or-break issue for the NHS over the coming years.
Over the past decade, day-to-day spending pressures have crowded out investment in the workforce. This must stop; this short-termism has not served patients, staff or taxpayers. The government has committed to a new pay deal for NHS staff and will be spending £20.5 billion more on NHS services by 2023/24. These are important and substantial first steps. But to tackle the current pressures in the workforce, much more action is needed, including more investment in training new staff and more support for the development and retention of existing staff. The health service cannot afford the government continuing to view education and training as an overhead cost to be minimised. There needs to be a fundamental shift in thinking to plan for ‘over-supply’ of key groups. If this were done and education and training budgets were increased, broadly back to the funding level in 2013/14, our analysis shows that the NHS has the chance to be self-sufficient – in nurses at least – in a decade’s time. But this won’t happen without investment, policy action and managerial focus now and sustained across the coming years.
In some other areas the management of staffing shortages requires even more radical action. The government has had a target to increase the number of GPs by 5,000 since 2016 (NHS England 2016). It is clear that this is not achievable. Over the next decade and across the NHS primary care will need to move to a wider team-based model in all parts of the country. Transforming primary care to a team model, shifting to train for over-supply, paying people competitive wages and investing in all staff so that they have rewarding jobs with terms and conditions which reflect modern life is critical to closing the staffing gap and delivering high-quality care.
But for the next five years we need to be realistic about what can be achieved – turning around the NHS’s staffing problems will not be quick. For the next few years the NHS can only maintain services by recruiting and retaining enough staff internationally. A positive culture and supportive immigration policy is essential alongside having NHS organisations that are ready to be good employers and help people settle. Even with this, the workforce constraints will inevitably shape and constrain the speed at which health services can be transformed and quality of care improved in areas such as cancer and mental
health.

There are no silver bullets for the workforce; addressing staff shortages requires consistent and concerted action across the system on pay, training, retention and job roles. While it is possible to point to individual policy failures in the past that have contributed to the current depth of the workforce shortages, the cause of our current problems goes deeper; workforce has not been a policy priority, responsibility for it is fragmented nationally and locally, the information the NHS needs to understand and plan its workforce is poor and the NHS has not invested in the leadership capability and skills needed to manage the workforce effectively. The NHS workforce implementation plan needs therefore to address not just specific policy areas but also the roles, responsibilities, skills and capabilities needed across the system for more effective workforce planning.
Finally, a key part of good workforce planning and policy needs to include thinking through how the NHS can work much more effectively with partners outside the strict confines of the health service. The past few years have clearly shown that good health depends not just on the NHS but also on the social care system; and an effective training pipeline of skilled staff requires strong partnership with further education institutions and universities, especially if we want to broaden the opportunities to ensure that the NHS has a diverse staff group that properly reflects the society it serves. There are a number of actions that can be taken to improve recruitment and retention in social care. However, workforce challenges in this sector partly have their basis in the poor pay, terms and conditions for social care workers. This can only be addressed by government, first through additional funding in the 2019 Spending Review, and in the longer term through comprehensive reform of adult social care funding.

Medical Schools: your chances – applications-to-acceptance ratio was 11.2.

NHS needs 5,000 trainee doctors a year

The NHS’s lack of GPs is so acute that ministers must boost the number of medics who train to be family doctors to a record 5,000 a year, the head of the profession is demanding.

The unprecedented rise in the number of GP trainees is needed urgently because the workforce has shrunk so sharply and waiting times for appointments have become so long, said Prof Helen Stokes-Lampard.

The chair of the Royal College of GPs urged the government to increase the number of trainees in England from 3,500 to 5,000 as soon as possible to relieve the strain on surgeries and burnout that are pushing so many to quit.

Boris Johnson will not be able to fulfil his pledge to shorten waiting times to see a GP or a longstanding promise to expand the workforce by 5,000 doctors unless his government ensures that over half of all medical graduates become family doctors, she warned.

Growing numbers of GPs are giving up as a result of a relentless rise in the demand for patient care and the impact of punitive changes to doctors’ pensions. The NHS lost 576 full-time equivalent GPs last year – one in 50 of the total – according to latest official workforce figures published last week. In June it had 28,257 full-time, fully qualified GPs, compared with 28,833 a year earlier.

“GPs and our teams are facing intense resource and workforce pressures and it is causing a growing crisis in our patients’ access to general practice services, which the prime minister pledged to address when he took up office,” Stokes-Lampard said.

“We need to think big, and based on current workforce trends the college estimates that we need to start training at least 5,000 GPs every year to meet the government’s overall target to expand the GP workforce by 5,000 full-time GPs.”

Johnson recently declared “it cannot be right that people are waiting so long to see their GP”. He has promised to improve access but not given any details so far.

Many patients have to wait more than two weeks to see a GP, according to the most recent evidence.

In a letter to Rishi Sonak, the chief secretary to the Treasury, Stokes-Lampard said the rise in the number of GP trainees would need separate funding to the £4.5bn extra that is due to go into primary and community care by 2023-24.

It costs the government an estimated £150,000 to fund a GP during what is usually three years of training, on top of the £250,000 cost of undergraduate medical training.

Although the number of full-time GPs in post is falling, the number of medical graduates entering GP training is at an all-time high. It has risen from 2,671 in 2014 to 3,473 last year, which was the first time the target of 3,250 had been exceeded.

Nigel Edwards, the chief executive of the Nuffield Trust thinktank, said more GPs would mean fewer graduates becoming hospital doctors.

“I completely agree that more GPs are needed. The current shortfall has seen patients’ experience of waits get worse year after year, and created a vicious cycle as overwork makes doctors retire early.

“But we do need to remember there are only so many medical graduates coming through, so realistically we would need to cut back on trainees going into hospital, which may not be easy. And more GPs coming in won’t solve this problem alone if burnout keeps pushing them away again.”

A Department of Health and Social Care spokesperson said: “We have seen a record number of GP trainees enter training and we expect that trend to continue this year. We have also created an additional 1,500 undergraduate medical school places and opened five brand new medical schools so that more doctors are beginning careers in the NHS.

“The NHS People Plan – published later this year by NHS England – will set out our plans for securing the staff we need for the future, including for primary care.”

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.”