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Junior doctors: the best kept secret in the NHS?
  1. Tim Swanwick
  1. Correspondence to Dr Tim Swanwick, Dean of Professional Development, London Deanery, Stewart House, 32 Russell Square, London WC1B 5DN; tim.swanwick{at}

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In designing a web-based tool to evaluate the knowledge and attitudes of foundation doctors in relation to patient safety, Jean Robson and her colleagues highlighted a fundamental disconnect between junior doctors and the organisations in which they work.1 In this pilot study, published in the November 2011 issue of the journal, trainees who reported patient safety incidents were ‘an unusual occurrence’; 48% of trainees surveyed believed that most safety incidents were due to things that they could not do anything about. Perhaps this is not surprising as a similar proportion reported that they had failed to be involved in any subsequent discussions about the prevention of similar events and only one-third had received any feedback following the incident's investigation. The author's proposal that an annual attitudinal survey would provide valuable information which to build more effective patient safety incident reporting structures may be missing a more fundamental point. The problem is deeper rooted than that.

Writing in the Journal of the American Medical Association last year, Robert Brook argues that physicians need to work beyond the reactive scope of traditional clinical practice and get out and engage proactively in the improvement of healthcare outcomes for entire communities and populations.2 The leadership of health systems—from the clinical team to the organisation—is not an option for physicians, argues Brook, it is a responsibility. In other words, healthcare is delivered by systems of people and processes working together and in order to deliver high quality care that is safe, effective and cost efficient, clinicians need to understand those systems, be able to work effectively within them, and to understand how to set about improving the way they work for the benefit of patient care.

All this requires a significant level of engagement of clinicians with the organisations in and around which those systems operate. The provision of effective healthcare requires a symbiotic relationship between clinical professionals, managers and the hard and soft systems in which they operate, delivering concerted efforts to drive up quality within available resources. In the UK's National Health Service (NHS) this has never been more important as the service attempts to meet a ‘quality, innovation, improvement and productivity’ challenge3 of achieving £20 billion of efficiency savings, while working to systems of financial incentives (eg, Commissioning for Quality and Innovation framework4) that aim to drive quality and safety improvement on an organisation-wide level.

At the front line of this endeavour are 50 000 ‘junior doctors’. Selected for their conscientiousness, problem solving skills and ability to work in a team,5 among many other relevant attributes, this youthful and energetic group should be at the forefront of health service improvement. But they are not. Strangely disconnected from their employers, trainees migrate from one service provider to another, single-mindedly pursuing curricula governed by one of a number of distant institutions—the medical Royal Colleges. As a result, trainees are often left with little sense of connection with their employers and conversely, employers with their junior medical staff. An equilibrium which fails to deliver on both sides, as clearly illustrated by Robson's paper.

We know that medical engagement in organisational performance makes a difference,6 so how can the traction between doctors in postgraduate training programmes and their employing organisations be improved?

First, there is a need to re-evaluate the trade off between clinical and organisational experience, reducing the speed at which students and trainees migrate through institutions. Without a sense of organisational allegiance, and conversely without an organisational duty of care, learners are kept at arms length, distanced from the business of healthcare delivery. Second, we need to build systems and processes that engage learners in the quality and safety improvement priorities of their organisation. In the UK, for example, all postgraduate trainees undertake a clinical audit every year. But the emphasis is on data collection, rather than change management and rarely is the work connected up with the organisation's improvement programmes.7 What a waste! Third, we need to invite juniors to step up into roles of increasing and graded responsibility and support them in leading projects and in taking ownership of some of the endemic problems of running a multibillion pound business. Fourth, we need to provide opportunities that help develop an appreciation of the wider healthcare system, the people and processes beyond the learner's immediate clinical domain. It is no longer enough to sit in the ‘splendid isolation’ of sub-specialist expertise. And, finally, we need to build strong networks that connect tomorrow's leaders, with physicians and the managers, nurses and other healthcare professionals growing into leadership roles.

If we can do all this, the rewards are there for the taking. Engaging junior doctors in the business of service improvement can significantly improve quality and safety of patient care and a number of innovative programmes across the UK—local,8 regional9 and national10—have shown us the way. Doctors in postgraduate training programmes are here, every day, at the front line of service delivery and have the capability, energy and enthusiasm to transform the NHS. Junior doctors may have been the best kept secret in the NHS, but it is time to let the cat out of the bag.


Thanks to Dr Fiona Moss who coined the title used for this editorial.


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  • Editor's note This article should have been published in the same issue as the article by Robson et al1 to which it refers. The journal apologises for the oversight.

  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

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