Junior Doctors in a 24/7 Working Hospital Friday 27 th November 2014 How does it work best for training Junior Doctors? Dr Tim Yates Academic Clinical Fellow & Specialty Registrar in Neurology Joint Deputy Chairman, UK Junior Doctors Committee Dr Darshan H Brahmbhatt Specialty Registrar in Cardiology & General (Internal) Medicine Joint Deputy Chairman, UK Junior Doctors Committee

Conflict of Interest DHB and TY are both doctors in training Both of our hospitals work 24/7

Disclaimer

“A stranger is a leader in a foreign city” – inscription, Ziggurat of Ur, c.2000 BCE

Overview BMA Policy Barriers to Training 24/7 Solutions: How to make it work best

(A sample of…) Relevant Policy BMA Junior Doctors Conference, 2014 That this conference: i) believes that, unless NHS funding is to expand, any move to 7-day services should focus on improvements to unplanned out-of-hours care before weekend elective working is considered; ii) notes and supports calls from consultants for access to the full range of in- hours facilities (such as radiographic, laboratory and other specialist services) if they are expected to provide an extended consultant presence in the interests of a safe and high quality service; iii) demands that juniors be provided with the same resources if they are expected to continue to provide 24-7 services; iv) notes that important barriers to discharging patients out-of-hours (and consequent hospital capacity issues) relate to the current working patterns of other health and social care staff; v) calls on the BMA to lobby governments to engage with all health unions to come to a sensible solution to the benefit of patients.

(A sample of…) Relevant Policy BMA Annual Representative Meeting, 2014 That this meeting: i) recognises that many doctors already provide seven day emergency services and insists that seven day urgent care must not be conflated with seven day access to routine services; ii) believes that delivery of both seven day routine and elective services is not feasible within the current NHS budget constraints leading to reduced clinical services Monday to Friday and/or closure of hospitals; iii) insists that provision of seven day healthcare requires investment in medical staff and supporting resources and not merely the reorganisation of services; iv) insists that any contract negotiations on seven day working must take account of infrastructure and support services, compensation for antisocial hours, and family friendly working.

(A sample of…) Relevant Policy BMA Consultants Conference, 2013 That this conference agrees that the quality of care should be equally high every day of the week but believes there is widespread misunderstanding of the potential benefit of 'seven-day working', since consultant care is already provided 24/7. Introducing elective work in evenings and at weekends would require not only extra consultants (since the limit on consultant time is 48 hours per week) but also extra non-medical staff. This is likely to be unaffordable in current financial circumstances. We call for an intelligent debate and financial analysis of what could and should be done 'out of hours' in acute hospitals.

Most (junior) doctors… …already work out of hours …understand the need to work weekend and night shifts, but… …don’t want to be routinely working nights and weekends …don’t want to be the only ones there

So how do we make this work? 1. Hours 2. Intelligent supervision 3. Stronger reporting structures 4. Empowered trainees

So how do we make this work? 1. Hours 2. Intelligent supervision 3. Stronger reporting structures 4. Empowered trainees

1. Safer Hours: WTR Agreed implementation 1998, 1 st limits 2007 with derogations, final limit 2009 Should have been easy to operationalise and assess but poor compliance after a decade No data this has helped patient outcomes, training outcomes, patient safety Trainee outcomes: more sleep, less training? No desire to see hours increase again

BMA 2006 Cohort in 2014

WTR implementation shows us how working practice change should not be done Do we better understand how working patterns place care and training at risk? - probably not

Smarter Hours: 24-7 Understand & manage fatigue –Errors, reaction times –Roman Generals –Breaks, shift length, cover arrangements –Facilities – rest, secretarial, administrative Manage intensity –Hot & cold –But bad for training if too hot –Time for reflection and abstract conceptualisation, as well as doing/delivering service –Staffing levels & skill mix RESEARCH DEPENDENT RESOURCE DEPENDENT

Safer, Smarter Hours: 24-7 Truly useful hours-reporting mechanisms –Real time data –Inform safe/unsafe limits –Collated with national oversight –Trainee satisfaction unlikely to be a good proxy Accommodating self-declaration of fatigue Culture and Systems

So how do we make this work? 1. Hours 2. Intelligent supervision 3. Stronger reporting structures 4. Empowered trainees

2. Supervision Level 24-7 agenda chance to bridge supervision gap as well as service gap Consultant supervision the new normal – is this best for training? –Is there greater value in increased supervision than there is in developed autonomy? –eg should consultants routinely review the ordering of all investigations by juniors? –Most trainees would not regard such close supervision as helpful – would consultants? –Is near(er) supervision a better compromise?

Understand 24-7 Supervision Enhanced supervision doesn’t always mean reduced perceived autonomy, but when or where pros outweigh cons is unknown Will lower levels of trainee autonomy & responsibility today translate into better patient care today? In 5 years? Must study impact on educational value and quality of future care before trainees’ autonomy is irreparably restricted

WTR imposed inflexible working changes that have altered training practices without prior consideration Trainees do not wish to fall into the same trap again

Intelligent Supervision Graded supervision from trainers, trainees need to be treated as individuals by systems Firm structure lost, therefore feedback needs to work better to close the loop Improvements in rostering, to fulfill training needs and meet service requirements more intelligently

Intelligent Supervision (2) Access to senior decision maker – especially in acute care setting Hub and spoke, rather than linear hierarchy Tailored development of trainee’s skills But all of this needs time

So how do we make this work? 1. Hours 2. Intelligent supervision 3. Stronger reporting structures 4. Empowered trainees

3. Stronger Reporting Structures Dysfunctional 24-7 potentially more damaging than badly implemented WTR Monitor hours – better systems to be developed NTS (“the post”) – maturing What about the person in the post? Must measure & reward the “right” things

If we can successfully measure what we’re doing, we will know when the changes we make are the right ones

So how do we make this work? 1. Hours 2. Graded levels of supervision 3. Stronger reporting structures 4. Empowered trainees

4. Empowered Trainees Trainees spend time learning things that have no relevance for their practice But not routinely taught safety culture/QI Trainees lack the tools that should empower them to influence organisation’s culture and shape their 24-7 working environments

4. Trainees to Empower 24-7 They are simply not equipped to empower 24-7 working at present And we don’t need to reinvent the wheel, as several reports have already shown us the path

So where do we go from here? All the camps have pressing work to do Own the safety and training arguments –Safe hours – employers, trainees –Intelligent supervision – trainers, trainees, GMC –Stronger reporting – employers, trainees, GMC –Empowered trainees – trainees, trainers, employers, GMC Current employment contract & EWTD are permissive to these changes

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