Tales from the wards - raising concerns

This month: Dr Guy Rughani tells about his experience of raising concerns about weekend cover as an F1.

As junior doctors we are encouraged by our tutors, hospitals, defence organisations and the GMC to raise concerns about the quality of care on our wards, but it's a daunting task. What if raising a concern somehow backfires? How will whistleblowing go down with our colleagues? Does the fact I've got an issue and no one else has complained before mean that the problem is me?

This year, a group of F1 colleagues and I raised concerns about the quality of patient care at the weekends, and the lack of adequate medical staffing.

As is common elsewhere, our weekend cover was a shadow of the team that worked Monday to Friday. On weekdays, a registrar and F1 covered the elective surgical patients, and a registrar and two F1s covered the acute admissions. At the weekend, a single registrar and F1 covered everything, plus admissions for another surgical team. This arrangement was okay when things were quiet, but as soon as it got remotely busy, or operations were delayed to the weekend and the registrar was required in theatre, the system failed and we felt that patient care suffered.

On a number of occasions whilst the registrar was in theatre, patients on the wards became unstable, leaving an F1 to lead their treatment. One sick patient was usually manageable, but when multiple patients were simultaneously ill the lack of readily available additional support left patients at risk. 

In addition, whilst the registrar was in theatre, no decisions could be made about patient admission or discharge, because as F1s we weren't allowed to make those calls. This meant that if there was a busy theatre list, patients languished in A&E waiting to be admitted, and patients who could have gone home remained on the wards. 

I talked to the other F1s on the firm who had also experienced these problems and contacted the Head of Department. The Head commented that previous F1s had made similar observations but had never formally complained. She encouraged us to write, and suggested a variety of senior hospital contacts. 

One quick email later and the Medical Education department, Clinical Director and senior surgeons were arranging an urgent meeting.  It was all a little terrifying how much of a stir the email had caused. I'd thought that the email might result in a meeting between us and a junior hospital manager, but it seemed to have gone right up the hierarchy. 

On reflection I realised that this wasn't the standard way of raising a concern and I hadn't really thought about the procedures we are taught before sending the message. I perhaps should have written to the F1 representative, or spoken to my Clinical Supervisor. Nevertheless, the concern was raised and the rapid response can only have been a good thing for the fundamental issue, patient care.  

In the first meeting the attending senior staff listened to our issues and drilled us for specific examples of where we thought patient care had suffered. We provided some evidence, but I was surprised at how specific they required us to be. At times it felt almost accusatory, however overall they seemed to welcome our comments.  

After the meeting there was talk that F1s would be withdrawn from surgical weekends with immediate effect. This was a potential disaster. I had hoped we had articulated that working weekends was on the whole a good experience, and one requiring just some minor changes. I felt that withdrawing F1s was a counterintuitive step. Unfortunately there seemed to be uncertainty between the registrars about who they'd be left with at the weekends, which got more frantic as the first Saturday post-complaint approached. 

In the end the weekend team went ahead as usual, with the on-call consultant asked to have a lower threshold for coming in. A week later the Clinical Director contacted us to discuss progress. The recommendations they had arrived at were encouraging; to reduce workload they advised that we should no longer cover the additional surgical team, leaving them to admit their own patients on Saturday and Sunday. To improve support and decision making they asked the weekend consultants to be more in attendance than before, and they have begun the process of creating a new SHO post. 

The experience of raising this concern was, in the end, a positive one. Whist next time I'll try and use the conventional pathways, I was pleased that our voices were taken seriously. The lesson: putting concerns into writing can transform F1 grumblings into positive drivers for change. 

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