Fiona Pathiraja: Putting a price on safety

Fiona PathirajaIt’s the first week of August and in the NHS that can only mean one thing. Changeover has arrived and thousands of newly qualified doctors are let loose on the wards.

For decades, patients and doctors alike have joked that it is best to avoid a hospital stay in August. Lately, this myth has been gathering evidence with suggestions of increased mortality around the changeover period. [1] Whilst by no means conclusive, the trend shouldn’t be ignored.

In an era of targets, safety, and patient-centred care, it is strange that the NHS has failed to tackle the changeover issue. The solution seems simple enough. New doctors need an efficient corporate trust induction that welcomes them to both the trust and the NHS. [2] Induction needs to be delivered alongside high quality ward-based shadowing that comprehensively covers vital first day competencies.

Paid shadowing and induction periods have demonstrated some improvement in safety, quality, and confidence of new doctors. [3] At present, this doesn’t happen uniformly across the country. A significant proportion of Foundation Year 1 doctors are starting jobs in unfamiliar hospitals, without a handover of patients and no understanding of the ward.

As with most things, the issue can be distilled down to money. Paying 7,000 new doctors for a week of shadowing and induction prior to starting their jobs is a hard sell in difficult times. But with more evidence trickling in to support a national shadowing period, I don’t think we can put a price on safety.

In the words of a newly qualified friend who started this week: “I’m running around like a headless chicken, trying in vain to be resourceful, annoying the nurses by asking them everything and praying that no-one gets really sick without the registrar being around.” Not really the best advert for safety, is it?

Fiona Pathiraja is navigating a medical portfolio career. She has worked as a junior doctor, management consultant, entrepreneur and most recently as clinical adviser to the NHS medical director at the Department of Health. Follow her on Twitter @dr_fiona

1. Jen MH, Bottle A, Majeed A, Bell D, Aylin P. Early in-hospital mortality following trainee doctors’ first day at work. PLoS One 2009;4:e7103
2. Stanton E and Lemer C. The art of NHS induction. BMJ Careers, February 2010
3. Pathiraja F and Outram C. Making the case for shadowing. BMJ Careers January 2011

  • We do a salaried induction for our FY1s-I think we are unique in this deanery at least in doing that. They start week before on a Wed doing ALERT, Thurs is ILS, Fri is a trust induction on infection control, safe IV cannulation, MEWS, right patient right blood and so on. Following this on Monday a Deanery induction and Tues is a day with the outgoing FY1s.

    On top of this we have an online resource of competencies for FY1s to complete including safe prescribing, death certification, and many other subjects which is checked by a completion online MCQ.

    If thats not enough they complete a 4 week apprenticeship in final year in the hospital in which they will take up first appointment.

    I don't know if this is best practice but patent safety is the premium here and if we value our young doctors and the care of the patients who need them then paying for attendance at induction must be right.

  • Completely agree that handover needs to happen, not just a few minutes but a few days of acclimatisation on the wards and in the hospital. Great article and significantly better than my rant on Black Wednesday at –…. Though we do have the same reference lol 🙂

  • Phil Anderson

    I think the F1 docs sometimes unfairly get landed with the whole blame for this, and we forget that on the same day F1s become F2s with a sudden increase in responsibility. As one of my fellow exF1 said to me “we're now on a rota with people who know stuff”

    As well as this, there is the unfamiliarity of a new hospital for everyone from F2 to SpRs, things get missed because the protocols are different, what was normally done by a Reg in one hospital may be done by an SHO in another etc.

  • C, sounds like Northern Ireland are ahead of the game then! There are sites of best best practice in England (East of England, South West) but long way to go before a uniform system. Also needs enthusiastic people like you to lead the schemes on the front line. Fi

  • Muir Gray

    there must be somebody, somewhere who has made this a littlebit less bad ? is there any one on The Network whp knows

  • There are areas of notable practice for paid F1 shadowing and induction in England (South West and East of England). They do this well but yet to be adopted across the country due to cost pressure and NHS Employer contract details for F1 docs. F

  • Peter Lachman

    This is a classic problem of trying to mend
    a broken system. The design is the problem – the archaic way we use trainees
    to provide service. One would never design the process in this way if one
    started over.

    We need have a radical rethink (read
    Clayton Christensen on this) and provide training and service in different
    ways. Patients should not be exposed to inexperienced trainees who are not
    supervised whenever they see patients.

    This will require reconfiguration and closure
    of units and the development of centres which provide real supervised training and
    centres which only provide service.  

  • Aias

    Νοone has addressed the real issue which is: has preparation for being a medical doctor deteriorated over the years and is so why? No corporate induction can ever compensate for lack of basic medical knowledge. Human beings are not Tesco products to follow protocols with

  • John

    This should be handled further upstream. I know practicing f1s that have never clerked patients by themselves and have graduated from medical school with merits and distinctions. I agree with Peter, but the system change needs more proximal input – from medical schools.

  • Thanks Peter for the ref – will definitely look it up! F

  • Thanks for the comment. Preparation for practice is being addressed around the country as med schools realise that their final years are not always ready for practice on the wards. Corporate induction is not supposed to compensate for knowledge. However, the NHS is missing a trick by not engaging these keen, enthusiastic new docs through a high quality induction programme in their first jobs.

  • Bernard

    UK medical schools (and I went to a leading London school) do not provide a proper apprenticeship for their students. Student numbers have been so inflated in the past decade that you have 4-6 students attached to each firm. No expectation to learn drug doses, how to dose warfarin etc, or in any way get stuck in on the shop floor. Time is taken up with tedious and banal form filling-in and box-ticking of competences and disingenuous “workbased assessments”. (This is continued into the foundation years and beyond – take one look at the nausea inducing NHS ePortfolio).

    Compare with American medical schools were students work parallel to interns (1:1 ratio) and work full days with almost identical responsibility for their patients, with an entirely different educational ethic and ambition. In this country until relatively recently, final year students could do House Officer locums, presumably dropped for medicolegal reasons.

    So, regarding the annual August “black Wednesday”, it is the effete educationalists' wrecking job of UK medical schools which we should be examining, not NHS employers. Virtually all F1s attend shadowing, paid or unpaid, out of professional commitment to achieve the best for their patients when they start. Trouble is, by then, it is sadly too late to truly prepare for the new working lives as doctors.

  • Anna

    My medical school made final years undertake 10 weeks of 1-1  F1-shadowing. On top of this when I started work a few weeks ago (South Thames Foundation School), I had a week-long paid induction period involving tours of the hospitals within the trust, talks from pharmacy and microbiology, IT training, an ALERT course, and further F1 shadowing. Despite all of this preparation my first few weeks as a doctor have at times been terrifying. I wouldn't say I'm undersupported, but at the moment I'm the only member of my team on the ward. All it takes is an SHO to be on leave, a registrar to be sick, and a consultant on holiday and suddenly you're flying solo, albeit with friendly back-up from doctors on other teams. I have numerous F1 friends (not just in my trust) who have experienced this – some in their first week. Adapting hospital rotas to ensure F1s are always supported/supervised by a more senior doctor during their fist few weeks would have an bigger impact on patient safety than a week's worth of induction training.