Context North Manchester General Hospital is a large District General Hospital in Greater Manchester, serving a relatively disadvantaged population. The overall culture change project involved practically all facets of a functioning medical organisation, including the Senior Medical Leadership Team (SMLT), Transformation team, Human Resources, Finance, and many more. However, one of the key aims of the change was to improve the experience of Junior Doctors working at NMGH. Therefore, postgraduate doctors in training have been key to all of the development, including the Medical Director’s Leadership Fellow (MDLF), Junior Doctors’ Leadership Group (JDLG), and every staff member that they represent.

Issue/Challenge Historically, North Manchester General Hospital (NMGH) has had a reputation as a poor place to work; staff aimed to avoid the site. The hospital was unable to retain highly-skilled employees, and trainee experience was extremely low, impacting on patient safety metrics. The site was stuck in a continuous cycle of having this reputation, leading to an inability to attract permanent staff, causing a deficit in teaching and training opportunities, further diminishing the reputation.

Rotational junior doctors are the most transient group of NHS healthcare workers (HCWs). Their experience is reflective of organisational culture and that of other, less vocal groups of HCWs. Prior to 2020, many junior doctors considered NMGH to be a ‘rite of passage’ ‘ one to be avoided if possible, but if unavoidable, just get through it. On-call teams were chronically short-staffed, 3 services were in enhanced General Medical Council (GMC) monitoring, and GMC survey results were unsatisfactory. Teams were forced to be tenacious, lateral thinking, and resilient to cope with the stresses of work.

2019 saw NMGH receive significant criticism from GMC and Health Education North West (HENW) monitoring visits. The General Surgery (GS) Department remained in ‘enhanced monitoring’, and patient safety concerns were raised. These included inadequate ‘prescribing of admission medication’, poor use of incident reporting systems, and challenges escalating sick patients. Trainees described ‘fire-fighting, not learning’. Improvement recommendations included addressing departmental culture, reinforcing the importance of incident reporting, and ensuring trainees had easy access to appropriate senior support at all times. Early in 2020, trainee experience further deteriorated in GS, due to a negative culture and deficiencies in support, education and training. This resulted in Foundation Year 1 doctors being removed from GS.

The Senior Medical Leadership Team (SMLT) decided that enough was enough; the hospital culture needed a fundamental overhaul. There was a clear and urgent need to address staff experience.

Assessment of issue and analysis of its causes

The Senior Medical Leadership Team (SMLT) set themselves an audacious goal: to support NMGH to transform into the best training and working experience for junior doctors in Greater Manchester. This goal was split into primary drivers, with each driver linked to specific future projects, and projects assigned to each leadership team member. These projects, identified through co-production with junior doctors, were aimed to improve employee experience, including facilitating access to breaks, improving supervision and support, and enhancing development opportunities ‒ aiming to raise staff wellbeing and patient safety standards. Changes were made to General Surgery, resulting in huge investments in expanding the permanent junior doctor and consultant workforces.

Several initiatives were implemented to help assess the scope of work required, including setting up a Junior Doctors’ Leadership Group (JDLG), or ‘Shadow Board’. All hospital specialties are represented; some representatives sit on the SMLT, on Educational Board meetings, and the Clinical Leaders Forum. The SMLT join every JDLG meeting. Whilst acting as a conduit for rapid two-way communication between clinicians and leadership teams (e.g. reliably informing doctors about last-minute changes to visiting policy during Covid surges, or effectively communicating crucial information to crash-call teams when building work closed part of the hospital), the group debates issues raised by junior doctor colleagues they represent, and feeds that back to the SMLT. Recent examples include raising patient safety concerns related to misinterpretation of the Emergency Department Referrals policy, and working collaboratively with junior doctors to address urgent staffing and patient safety risks related to the last wave of the pandemic.

In addition to this, a Medical Director’s Leadership Fellow (MDLF) role was established. This was fundamental in progressing projects related to the SMLT goal and ensuring appropriate input from junior doctors, Human Resources, the Communications and Transformation teams, and more. As a key member of the JDLG, the MDLF is a role designed in part to enhance junior doctor experience, foster better relationships between staff groups, and encourage feedback provision. The role has been vital in bridging the gap between doctors and hospital leaders, managers and executives – often a source of discontent amongst clinicians. Bridging this gap is important in developing the hospital’s culture. Even though many projects are still ongoing, improvements are already being experienced.

Impact 2021 GMC Survey results showed improvement in 15/18 metrics compared to 2019. These included improvements in ‘Reporting Systems’, ‘Workload’, and ‘Clinical Supervision Out Of Hours’. 2020 Care Quality Commission inspection reports showed improvement in 11 individual aspects, including improvement to ‘outstanding’ in 3 elements.

HENW/GMC monitoring visits in 2021 reported ‘they have more robust teams to support the ward and on call workload’, resulting from investment in clinicians. It also notes, ‘prescribing audits have shown improvements in prescribing of time critical medication’, and demonstrable improvements in ‘use of incident reporting systems and sharing of lessons learnt’. Further comments note that there have been ‘significant improvements in culture in the [General Surgery] department over the past year’; one doctor described the department as ‘the most supportive place he had worked’. The report summary noted, ‘through strong clinical leadership and oversight, and a concerted effort to improve departmental culture there have been significant improvements in General Surgical trainee experience with good support, supervision and education reported’. The department was subsequently removed from enhanced GMC monitoring.

Although this rapid and impressive turnaround occurred within one department, benefits were seen elsewhere in the organisation.

The efforts of the SMLT and JDLG have resulted in positive cultural changes. Surveys reflected: ‘friendly colleagues, less work-related stress, helpful management’, and ‘thank you for your work to improve NMGH. I was worried about working at NMGH having heard ‘horror stories’ about working there. However, these have not been reflected in reality at all, and NMGH has offered excellent training opportunities.

Intervention The JDLG helps ensure that important information is shared with the wider junior doctor group. Colleagues now feel that their voices are heard. The positives from the previous culture are still evident – leadership teams across the Trust have repeatedly recognised the ‘can-do attitudes’ of NMGH staff, with the negative culture firmly in the past. Staff testimonials include: ‘there has definitely been an improvement over the years I have worked here; ‘my supervisor was supportive and encouraged reflection through discussions about experiences; and ‘the senior staff are INCREDIBLE. They offer support, they teach, and they encourage us to learn new skills. I cannot be more thankful’. This is in contrast to historical Freedom To Speak Up (FTSU) submissions, which pointed to a culture of disregarding the opinions of NMGH staff.

The ‘can-do’ approach has been evident during the waves of Covid-19; members of the JDLG fed into management and governance structures to highlight problems in real time, increasing the organisation’s responsiveness to challenges faced, working as a two-way conduit of information.

During the 2021 HENW/GMC visit, the team reported that junior doctors knew the Medical Director and Director of Medical Education by first name, and felt able to raise concerns directly to them, evidencing a more flattened hierarchy. The visiting team reported being impressed by this positive change and were not aware of other organisations where this had been achieved to this extent.

Having Postgraduate Doctors in Training play such a significant role within the Senior Leadership Team setup is relatively unique. As explained, empowering staff to feel they can raise any issues directly to the Medical Director or SMLT, or via the JDLG, has played a huge role in facilitating palpable cultural change through leadership structure additions. As a point of contact, the MDLF has acted as an extension of the JDLG, but works directly alongside the Medical Director and Associate Director of Medical Education, essentially enabling the SMLT to keep their ear to the ground, their fingers on the pulse of staff atmosphere and wellbeing.

Examples of achievements of the MDLF include projects to introduce personalised theatre caps (benefits include enhanced communication, especially in emergencies, improving patient outcomes), formation of a Wellbeing group (representatives from all cohorts of staff across the site discuss wellbeing initiatives and colleagues’ wellbeing concerns), and an impressive and rapid response to staffing crises and patient safety risks during the most recent Covid-19 wave. As a result of these outcomes, other Trusts have approached the SMLT, requesting further information regarding the JDLG and MDLF model; another MDLF has since been appointed at a different trust site.

Involvement of stakeholders, such as patients, carers or family members:

The SMLT itself is made up of clinicians from a variety of backgrounds, across medicine and surgery. SMLT members sit in morning medical handovers to actively gather clinician experience feedback. They also work closely alongside colleagues from Nursing, Finance, HR, Transformation teams, and more, which enables the SMLT to work collaboratively with the multidisciplinary team to improve culture at NMGH.

The MDLF is in the perfect position to take advantage of this MDT approach. As a result, the MDLF sits on Group-level Patient Safety Panels (acting to highlight patient safety incidents, initiatives, and achievements across the entire Trust). This panel consists of representatives from hospital, community, and medical education staffing groups. The lessons learnt are then communicated to individual hospitals, no matter where the incident or initiative originated. A big part of the meeting is the FTSU aspect, and local FTSU Guardians are active within the panel.

Given that the MDLF role is so closely linked to improving communication and feedback, a Freedom To Speak Up Champion role fitted well within the responsibilities of the post. Therefore, over the past year, the MDLF has worked alongside the FTSU team and has completed training as a FTSU Champion. As a consequence of working closely with shop-floor colleagues, the MDLF has received communications from a wide variety of staff roles and levels of seniority throughout the year, asking questions, or raising awareness about issues. The MDLF can then seek appropriate advice, signpost the colleague, and keep them updated on a potential resolution, further propagating the positive feedback loop and support of the wider MDT.

As previously mentioned, the JDLG consists of representatives from all medical specialties, and each member is encouraged to raise concerns, suggest improvements, and lead on projects; these include an overhaul of the medical handover process, enabling a safer and more efficient handover, and escalating concerns of a colleague speaking up about potential patient safety concerns within a department. Furthermore, speakers at JDLG meetings have included the Head of Nursing: Quality & Patient Experience, local FTSU Guardians, the Director of Human Resources, and the local Guardian of Safe Working Hours, enabling group members to share information from a wide range of disciplines with shop-floor colleagues.

As a result of the efforts and MDT approach of the above groups, a placement feedback survey performed early in 2022 demonstrated that 93% of respondents felt their working environment supports a multidisciplinary approach.

Key Messages One of the hallmarks of good medical leadership is putting all staff members, regardless of their role, seniority, or experience, in the best position for them to succeed. Giving Postgraduate doctors early opportunities to play a significant part in, and learn about, an organisation’s leadership structure, is not only beneficial to the doctor, but helps the organisation capitalise on a previously relatively untapped market of ideas and solutions. Crucially, this is not limited to postgraduate doctors in training, but also locally-employed doctors, which make up a significant proportion of the workforce in any hospital yet typically remain underrepresented and under-utilised.

NMGH has realised the potential that can be unlocked in Junior Doctors, through leadership placements and roles, and the positive benefit this can have on the individual, team and organisation.

Lessons learnt North Manchester General Hospital was fortunate in that the entire SMLT bought into everything: the overall project for culture change, the introduction of the MDLF into the SMLT, and empowering members of the JDLG to contribute to change at the highest level. Having spoken to other organisations looking to replicate our success, they have found that this buy-in is absolutely crucial. Recruiting effectively, to both the MDLF position and JDLG representative roles, is vital, as a huge amount of motivation to fight for change and the betterment of the system is required when overcoming barriers and challenges. Many of the barriers we faced are well-documented in literature, and to a point we expected them; these included resistance from non-medical stakeholders, which was somewhat abetted by further conversations, explanation of goals and objectives, and outlining the overall vision of the SMLT. Of course, resistance to change is important in any project, as it can highlight potential issues not yet visualised.

Measurement of improvement From the start, we set out our intention to use openly-available, independent metrics of improvement, such as the GMC Nation Training Survey. To compliment this, the MDLF utilised a variety of temperature-check methods, including surveys (dissemination supported by the increasingly-established network of the Postgraduate doctors in training of the JDLG) and departmental visits. Importantly, having a fellow junior doctor asking for feedback, rather than a traditional member of the SMLT, enabled us to garner potentially more honest opinions, criticisms and ideas. As explained elsewhere, GMC survey results have shown improvement, and local surveys have displayed some very positive results. That said, it is recognised that the vision is a long-term project, and continuous improvement will be sought, rather than settling on the progress made thus far.

Strategy for improvement The SMLT sat down and brainstormed an overall vision alongside the individual large-scale projects that would contribute to achieving change. Within this, individual members of the SMLT were assigned roles leading one or more projects, and the MDLF role was created in part to support with the running of these projects where required. This enabled utilisation of the minds of the JDLG and other Postgraduate doctors in training. The MDLF role was instrumental in not only involving this cohort, but also reaching out to other organisations to share learned experiences when they had gone through implementation of similar projects. The team was kept accountable not by having a set timeline for implementation but by having regular away days, reporting back to their colleagues and the transformation team regarding progress.

The JLDG, established in 2020, and reappointed every year, have been key to the success of the culture change, through engagement, sense-checking and feedback regarding strategy and relevant projects. Over time the organisation has increasingly engaged this Shadow Board in the development and role out of projects as well as problem solving of significant challenges. Through this team the SMLT has fedback key messages and challenges to the Junior Doctor workforce, which has resulted in increased engagement across the organisation.