The main focus of the recent Francis report has been on the implications it has on the clinical and economic management of the NHS, but there are many lessons that can be applied to all levels of hospital hierarchy.
Patient centred care is championed across healthcare, and nowhere as much as in complex care wards for older people, such as the one I’m currently placed on. The increasing number of admissions for older people with complex comorbidities and backgrounds means protocols and standardised treatments, although useful, are continuously being adapted for patients’ needs.
By contacting the family of any patients admitted onto the ward within 24 hours, the team I am currently working with ensures a comprehensive plan based around the patient and their family can be put into action quickly. Junior staff are usually the ones creating this patient-family-staff collaboration, which puts them in a unique position to take charge of the patient’s situation, while encouraging patient autonomy. This early contact facilitates a culture of “openness, honesty, transparency, and candour” from all parties if any issues arise.
The Francis report points out the lack of accountability across the NHS, and, although ultimately this ends with the consultant in charge, I believe encouraging a culture of ownership among junior staff will ultimately improve standards of patient care. By nurturing a vested interest in the patient, consultants can feel confident with their team’s management plan.
This requires a trusting relationship between juniors and their seniors. By being dismissive and overscrutinising work, consultants can create an environment where juniors lack the confidence to initiate any further management, thus slowing the patient’s progression and ultimately affecting patient care. This culture also relies on all members of the team, not just doctors, to feel at ease that any issues highlighted, or questions posed are dealt with, not at a personal level, but with the sole focus of improving patient care.
Again the need for more clinical leadership is an issue highlighted in the Francis report. I believe in order for this to become commonplace, it must start from the bottom up. It is easy to see how senior members of staff who have worked in the same hospital for many years can fail to acknowledge issues that have become the norm around them. Junior doctors who rotate hospitals and wards regularly are in an optimal position to compare different delivery of care and suggest service improvements.
By allowing junior doctors to take on roles on boards involved in commissioning and decision making, their ideas will feel welcomed and can be shared. Patient care improvements need to be facilitated by those who create the patient-service interface.
Changing the culture within any organisation takes time, but hopefully recent reports from Mid Staffordshire and Stoke Mandeville can be a catalyst for change. Junior doctors and students are often well aware of issues on the wards, but lack the knowledge, courage, or system to be able to pursue this. Changing the NHS may be difficult, but changing ourselves will be harder.
Sam Fosker is a final year medical student at Brighton and Sussex Medical School. His interests are in paediatrics and acute care medicine. He has been involved with various projects including co-organising the first National Medical Student Paediatric Conference and he has carried out research into upper limb injuries while on his elective with a mountain rescue team in New Zealand. He fills his spare time with various sports as well as helping to write and direct the local medic revue.
I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.