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Surveying, Shoring, Strengthening: Rebuilding Medical Morale from Its Foundations

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Surveying, Shoring, Strengthening: Rebuilding Medical Morale from Its Foundations ORIGINAL REVIEW RESEARCH ClinicalClinical Medicine Medicine 2019 2017 Vol Vol 19, 17, No No 4: 6:282–9 282–8 S u r v e y i n g , s h o r i n g , s t r e n g t h e n i n g : r e b u i l d i n g m e d i c a l morale from its foundations Authors: A r r a s h Y a s s a e e , A L a u r a C h e e t h a m , B N i c k M a n n i n g - C o r k , C C a s s i m A k h o o n D a n d A r j u n G o w d a E is currently being reviewed by the British Medical Association and Significant uncertainty surrounds the sustainability of 3 healthcare services in which junior doctors work. It is essential NHS Employers. that student and foundation doctors (SFDs) are actively Undergraduate medical education in the UK is between 4 to engaged if workforce morale is rebuilt. This narrative review 6 years in length. Prior to specialty training, UK medical graduates explores the evidence driving the individual work-streams of also complete a 2-year Foundation Programme (FP) that rotates ABSTRACT the Royal College of Physicians’ newly formed Student and trainees through placements, delivering a broad curriculum Foundation Doctor Network. Undergraduate and postgraduate predominantly through experiential learning. While this period training reform has coincided with concerning feedback from cements trainees’ continuing postgraduate development, these newly qualified doctors. System-level efforts to address this doctors represent the foundations of the profession's future. include a focus on extra-contractual matters, where small, With uncertainty around what their future professional working sustainable changes could address training and work issues. lives in the NHS will resemble, student and foundation doctors Fewer foundation year-2 doctors are entering specialty (SFDs) may feel justified in considering their commitment to training immediately after the foundation programme. Provid- a long-term career in healthcare. It is imperative that they are ing dedicated careers guidance and highlighting opportuni- actively engaged and consulted if morale is to be rebuilt and ties within traditional placements and other career paths can whatever ‘fractures the relationship between physicians and the 1 support doctors who undertake non-traditional career routes, state’ is to be addressed. including those who take time out of programme. Recently the Royal College of Physicians (RCP) established its Disseminating these resources through an effective peer- Student and Foundation Doctor Network (SFDN). Representatives to-peer framework and a well-established mentoring scheme from across the UK meet regularly to discuss pressing issues could be the most appropriate way to spread good practice. affecting SFDs and how the RCP could address them. There are three work-streams: working lives, to survey the challenges within K E Y W O R D S : Foundation , training , morale , workforce , trainee the foundations of junior doctor morale; careers development, to shore up these foundations; and local engagement and communication, to strengthen them for the future. In this narrative review, we explore the evidence behind these Introduction goals. The review will explore recent reforms, successful solutions employed locally or in other sectors. We also illustrate the value In April 2016, the NHS in England endured the first all-out ‘junior SFDs can provide to policy by outlining a SFDN project. doctor’ strikes (encompassing both elective and emergency services) in its history. 1 While contractual negotiations sparked the decision to ballot junior doctors, pre-existing and SFDs’ working lives longstanding problems with junior doctor morale exacerbated the dispute.2 This distinction is particularly pertinent given that The past 15 years have seen major reforms to undergraduate the terms and conditions of service for junior doctors in England and postgraduate training, including Modernising medical careers (MMC) which saw changes to specialty registrar training, first year of medical practice (pre-registration house officer) and the senior house officer system.4 The latter two changes resulted in the Authors: A specialty trainee year 1, paediatrics, Barts Health NHS genesis of the FP (Table 1 ). Trust, London, UK ; B core trainee year 2, Acute Care Common Stem Critics argue that MMC has resulted in a more inflexible training (anaesthetics), Aneurin Bevan University Health Board, Newport, structure which contributes to trainee attrition. Many also argue U K ; C foundation year-1 doctor, East Kent Hospitals University that it has resulted in the weakening of informal support networks NHS Foundation Trust, Canterbury, Kent, UK ; D post-foundation through the loss of the firm and diminishing use of the mess. 6 programme doctor, Buckinghamshire Healthcare NHS Trust Solutions to address this have been varied and have included Amersham, Buckinghamshire, UK ; E post-foundation programme placing some postgraduate responsibilities on medical schools. 7 doctor, Nottingham University Hospitals NHS Trust Nottingham, Similarly, the Shape of Training review and a subsequent General Nottingham, UK Medical Council (GMC) report draw attention to the effect 282 © Royal College of Physicians 2019. All rights reserved. CMJv19n4-Cheetham.indd 282 6/29/19 8:27 PM Rebuilding medical morale from its foundations Table 1. Examples of challenges of previous pre-registration house officer and senior house officer grades with relevant changes included in the Foundation Programme to address these. Challenges of the PRHO/SHO system Change built into Foundation Programme Short, stand-alone SHO placements with no overall co-ordination Coordinated set of three to six placements designed to provide a of training balanced learning experience No common competencies across placements Nationally agreed curriculum with minimum common competencies Lack of standardised end-of-placement assessment Standardised end-of-placement reviews conducted through e-portfolio Local, varying and often duplicated application process; Single centralised, national, standardised application process requirement to apply for each SHO job every 4–6 months allocating 2 years of placements; occasional deaneries require selection of F2 placements based on F1 portfolio score Service delivery and training imbalance with little accountability of Aim to readjust this through mandatory, weekly teaching training quality requirement with specific national feedback surveys on training quality Numbers of jobs based on local junior doctor need rather than Numbers nationally agreed, based on predicted workforce workforce demands requirements Placements not allowing for specialty-specific competencies Focus in Foundation Programme on broad-based, generalisable skills as per General Medical Council's duties of a doctor5 Lack of formal career advice Requirement for formal careers advice and access to services Disparity between PRHO year reviewed by medical schools but F1 sign off by postgraduate dean, assessment based by trusts acting as PRHO employer Foundation Programme director in trust. Limited placements variety with excessive focus on secondary care Broader range of available placements with recent commitment to ensure more foundation doctors undertake a community placement Variable and often lacking supervision Requirement to have allocated clinical and educational supervisor; national surveys assess level of day-to-day supervision F 1 = foundation year 1; F2 = foundation year 2; PRHO = pre-registration house officer; SHO = senior house officer of recent reforms on trainee experience, training quality and This highlights the difficulty of the sharp transition from medical workforce retention. 8–10 student to practising physician with frequent rota gaps and often Undergraduate curricula and its delivery have also been scarce senior availability. 17 These findings also demonstrate that progressively modified in line with sequential GMC guidance – training reforms often fail to take a holistic view of the pressures from ‘Tomorrow's doctors’ to Promoting excellence: standards experienced by FDs, with recent reports identifying that these for medical education and training . 11,12 Most notably, practical are linked to worsening workforce retention. 9,10 Curricula and skills training has shifted from a ‘see one, do one’ format to programme design would be enriched by a greater awareness of initial simulation and/or clinical skills laboratory training followed these pressures, some of which are outlined in Table 2 . by competency-evidenced skill practice. This, in part, reflects Recent system-level efforts to address these challenges include changing sector-wide approaches to safety. 13 the 2016 terms and conditions of service in England and the However, these reforms have coincided with concerning feedback. ongoing FP review. 42 Key stipulations, including improved limits on The GMC surveys cite that reported preparedness for practice of safe working hours, a system to report deviations from planned new doctors rose from 26% in 1999 to 58% in 2005. After the rostering arrangements as well as the creation of the ‘guardian introduction of the FP, improvements stagnated, with only 49% of safe working hours’ role, are designed to address issues of 2009 graduates feeling that medical school had adequately surrounding overtime and missed breaks. prepared them for practice. A more in-depth study found further Provision of hot and cold sustenance and facilitating rest breaks evidence of poor self-reported preparedness. Graduates, in addition for doctors on long shifts are examples
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