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Thursday 28 September 2017

Talking treatment: how to engage with junior doctors

By Matthew Limb

Everyone wants to involve more clinicians in managing the NHS, but junior doctors are a notoriously difficult group to engage. Matthew Limb spoke to Imperial College about an innovative scheme that's already bringing results.

Imperial College St Mary's Hospital

Senior managers in NHS trusts have a key role in setting the right tone and culture within the organisation, and an increasingly important part of that is building trust and improving communications with frontline medical staff.

"I feel that this is essential in creating an environment that's open, honest and set up to deliver the high-quality care we aspire to," says Claire Braithwaite, director of operations for medicine and integrated care at Imperial College Healthcare NHS Trust in London.

Evidence suggests engaged medical staff enjoy increased job satisfaction, and have lower rates of absenteeism and burnout – leading to better safety outcomes and a better patient experience. But every workplace is different and the needs of staff groups vary, so finding a workable approach can be challenging.

Braithwaite says she realised two years ago that the trust had to improve trust and communications with staff generally. "Our staff and GMC survey results weren't brilliant," she admits. And according to James Hatcher, a former junior doctor and now a consultant at the trust, "a lot of junior doctors felt, rightly or wrongly, they were not listened to for certain things".

Braithwaite led a programme to improve engagement with junior doctors, a group that is often hard to engage because of the short nature of rotations.

"The outline plan was to ask some junior doctor representatives to come and sit on our divisional management committee to help in day-to-day running of the division," she explains. "We had a number of major change projects coming up that would have a big impact on junior doctors and we needed their help and support to make sure we got that right."

Junior doctor reps

The trust set up four junior doctor representative posts, paying each an additional £3,000 a year to improve engagement and contribute their expertise to decision-making. This involved drawing up what Braithwaite admits was an initially "vague" job description and adverts aimed at tempting "willing people" to take part.

The strong response provided managers at Imperial with new insights into how to improve engagement. 

"We got a view on life that I'd never heard before in terms of the reality of what it's like on the frontline of clinical care and how some of the things we were doing affected people in a way that I'd not quite appreciated," says Braithwaite.

'We got a view on life that I'd never heard before, of the reality of what it's like on the frontline of clinical care.'

Claire Braithwaite: "We got a view on life that I'd never heard before, of the reality of what it's like on the frontline of clinical care."

The first challenge for the newly-appointed representatives was to work out the best way to engage and start conversations with junior doctors generally. The new junior doctor representatives attended the divisional management committee and the quality and safety committee, and had equal status with other members. Braithwaite says opening up the committee for the first time to staff who had no management training was very important and "covered off what we felt was a blind spot in terms of decision-making".

An example of this approach in action was the reconfiguration of acute medicine services at Imperial's St Mary's Hospital to meet new standards for reviewing and assessing patients arriving through A&E – changes which required extra consultant cover.

"In order to make that work in a way we wanted, we needed to do some quite significant redesign of the junior doctor rotas and one of our junior doctor reps took the lead on doing that, helping to set up all the engagement and consultation meetings," says Braithwaite.

"It helped us to understand what would help junior doctors, even around timing of meetings and things like that. Therefore, the process went much more smoothly than I think it otherwise would have done. We ended up with something we were happy with and, most importantly, the people who were going to work on those rotas were also happy with."

The representatives also came into their own by helping to improve internal communications during the recent national junior doctors dispute, resulting in "more informed" discussions on the management committee, and better understanding among junior doctors of the trust's view on the strikes and how they would affect services.

"I think what could have been a very difficult situation actually passed of much more smoothly because we already had a forum to have a dialogue with people we knew reasonably well," says Braithwaite. "It helped us to identify what some of the operational challenges were going to be and put contingencies in place in order to work around them. So difficult issues were much more straightforward to tackle and talk about."

Getting results

Hatcher, one of the very first reps on the programme, says it was especially effective in preparing him for his new job as a consultant in infectious diseases and medical microbiology at the trust. "It helped me to understand the systems you don't get involved with on a day-to-day basis as a junior doctor," he explains. "That gave me lots of contacts and it was inspiring to talk to people outside my small specialty.

James Hatcher: "It was inspiring to talk to people outside of my small speciality."

"I was able to grow and learn with regard to my management experience and leadership skills," he adds. "I was able to voice opinions but also to make those connections with other people to drive change and different ideas. That two of our reps are now consultants at Imperial – both have leadership roles within the organisation – I think in itself kind of demonstrates what a success it's been."

The trust has received more applications for rep posts each time they've been advertised and the appointed reps come from a wide variety of grades and specialties.

Braithwaite is keen to get reps involved in new projects, with one rep now reviewing the trust's complaints process. The idea is to work out how better to use clinical teams to support patients in getting issues resolved before they make a formal complaint.

Junior doctor reps are also helping to deliver a pilot project to improve the quality of clinical coding, conducting an analysis of stress levels among junior doctors and redesigning the senior house officer role at Charing Cross Hospital.

Braithwaite says the trust has shown it has both listened to and acted upon junior doctors' concerns.

Although she admits the trust could have implemented some projects without the rep model, both she and Hatcher agree change has been more successfully implemented as a result of the scheme.

"A significant amount of time and effort goes into planning and implementing our engagement strategy and the introduction of the junior doctor representative role was an important part of this," says Braithwaite. "We've been tracking staff engagement scores and things that come through on the GMC survey and generally those things are moving in the right direction." 

The division achieved its highest ever engagement scores, both overall and for training grade doctors, in the 2016 NHS Staff Survey. The GMC survey results for the division have also improved on previous years.

"It's difficult to know whether these projects would have happened anyway or how successful they may have been with or without a junior doctor," says Hatcher. "But if you are retaining staff that then take on leadership roles by engaging them earlier as junior doctors, that's a real success, because it's the path we really want to develop in clinical medicine in the NHS."

Matthew Limb is a freelance journalist and regular writer for the BMJ.

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