Robin Baddeley: Should UK training programmes have doctors based on one site for two years?

A “residency model” may help rebuild bonds between doctors and their employers

David Oliver recently called for urgent action on the issues affecting recruitment and retention of junior doctors. While the responsibility for these matters is spread over a number of organisations, the complexity of the workforce issue should not detract from Oliver’s appeal for urgent action; these issues have been well recognised for some time now, and further delay in demonstrable progress is difficult to justify. But to truly bend the recruitment and retention curve for the better, we may also need to confront an obstacle intrinsic to the way we train our doctors: the frequency with which trainees rotate through hospitals.

Despite the appearance of sympathy for junior doctors’ cause from senior medics and national governance bodies, there are those for whom junior doctors’ demands are simply born of millennial entitlement. While there may be elements of truth in such an accusation, it is an oversimplification. Frequent rotation between hospitals is not a new phenomenon for trainee doctors in the UK. But historical approaches to training benefitted from important mitigating factors; hospital doctors worked in “firms,” would usually manage the “on-call” with the same cohort, and often lived in on-site hospital accommodation. These circumstances and customs played an important role in bonding a junior doctor to their work in ways which are now rare. A transient group without those meaningful ties can be left feeling powerless. In the millennial era, one way for trainees to construct a sense of agency and power is to take their skills and loyalty elsewhere. This manifest disengagement may be contributing to the rising rate of attrition from training programmes.

A “residency model,” where trainees work and train within the same hospital for two years or more, may help rebuild those bonds between doctors and their employers, with the subsequent gains in workforce morale, retention and recruitment. A programme which establishes trainees as a more permanent presence, with regular positions on hospital committees, would better recognise those trainees as a valued and influential group within the hospital. In the U.S, for instance, the intake of residents is often proudly celebrated by their photos and biographies on the walls: they are seen as an investment.

But the relationship is reciprocal: while trainees are invested in by the trust, they too are invested in their hospital, bringing numerous benefits. Greater familiarity with hospital processes increases efficiency, with the consequent benefits for both patient care and trainee fatigue. Local quality improvement would thrive: the prospect of one’s own cohort benefitting from system change creates a stronger incentive for trainees to engage in appropriate and meaningful projects. Fewer changeovers, with continuity within the trainee cohort, would soften the perennial rota issues which plague trainees’ ability to plan their lives. Time and familiarity with the wider body of hospital staff would foster stronger relationships and interdisciplinary cohesion. And importantly, it wouldn’t cost a load of money. From the employing trust’s perspective, trainees who possess frontline knowledge of the workings of their hospital are clearly a valuable commodity. But the success of such a training model is dependent on a clear understanding of the reciprocal relationship: training concerns must be acted on rapidly and comprehensively, and if not met, trainees are pulled from the service.

There are usually two main arguments put forward against long placements. The first concern is that trainees could end up stuck in a “failing” hospital for two years, and be miserable. But “spreading the misery” amongst a cohort of trainees is not a solution for failing hospitals, and furthermore, a longer placement is a powerful incentive for trainees to improve failing systems from within, rather than ‘tolerate’ them for a short period until they move on. The GMC have the power to intervene in hospitals which cannot meet training needs, and there would need to be a high level of trust in this process from within the trainee body. The second concern is that not all hospitals provide the array of specialty experience to meet training requirements. There is merit in this concern, and there would need to be some flexibility, particularly during specialist training. However, most hospitals provide the core specialties needed for the first few years of training. These are all valid concerns, but the potential benefits of longer placements would suggest that the proposal warrants a debate.

There is much talk about how the health service could be seen to be “investing” in junior doctors: should this involve structural changes to training programmes? There is merit in exploring what we may learn from how other nations accommodate their trainees. Importantly, any debate should not delay tackling the low-hanging fruit mentioned in David Oliver’s article. But there may be other ways to sew some of the junior doctors’ enthusiasm back into the institutional patchwork.

Robin Baddeley, editorial registrar, The BMJ.