Introduction NHS services are facing a rapid expansion in demand (up to 7% annually), so the need for fully trained Drs is increasing. Meanwhile the latency on training a Dr remains long: nearly 10 years from commencing medical school to being an independent practitioner. It is hypothesised that the increased tempo of working (seeing more patients in reduced time) may come at the expense of high value learning opportunities, impacting on the quality of training. However this proposition remains unproven. Further challenges are the reduction in continuity of care (Calman-Temple-Junior Dr Contract), the scarcity of experienced trainers and the paucity of ideal learning opportunities and conditions. This study sought to explore the tension between service provision and training postgraduate Drs, as potentially competing demands within a NHS Trust. It used a systems design approach borrowed from the space industry and a systems thinking principles to comprehensively model this tension.

Aims and objectives of the research project or activity Aim: to apply principles of Systems Thinking to model the tension between service provision and training postgraduate Drs in a medium-sized DGH, using heuristics for identifying conflicting requirements.

Objectives:

1. To articulate key system Requirements and Resources, in the functional (transformational) domain of the system in fulfilling its stated purpose(s)

2. To apply Salado’s Tension matrix, to model the tension between the use of identified (finite) resources, when aiming to meet the nominated system requirements

3. To identify contested resources, which are mutually depleted by the fulfilment of system requirements – this will constitute identified tension within the system

4. To explore nested structure (sub-systems) and institutional boundaries inherent in the present situation

Method or approach Methodological approach: ‘requirements are boundary conditions against which the design activity occurs.’ This tests the belief that it is difficult to fulfill conflicting requirements when they are dealt with simultaneously.

Methods included unstructured interviewing (snowball sampling/questioning) of key individuals spanning operation and clinical management within the Trust, and across regional and local training/education. This included the Trust COO, Clinical Directors, Director of Medical Education, Guardian of Safe Working, Local and Regional programme Directors, HEE Leadership Associate Dean, Patient Partners and Postgraduate Drs.

Crucial outputs included their views on hospital requirements in fulfilling service provision and training, considered as separate concerns. Resources were also discussed.

The ‘Tension matrix: Requirements, Resources and Elemental decomposition’ model (Salado et al., 2015), was completed to explore tension, with an artificial interface created between requirements necessary for service provision and training.

For interest, boundaries and nested structures were illustrated with a simple systems map.

Findings Functional requirements were successfully identified. This demonstrated encouraging concordance with both the hospital’s stated strategic objectives and also with identified themes found in the literature relating to performance measurement and improvement. Resources were then identified, yielding much qualitative material for consideration and discussion.

Salado’s Tension matrix was constructed and tension was identified when different requirements competed for the same resource across the service provision-training interface.

Conflict over consumption of resources was not uncommon, this was most significantly found in supervisory capacity which is both key for service delivery (in a consultant-delivered service model) and in training (as faculty is a barrier to training expansion). Supply of high-quality resources was more commonly a limiting constraint over finance. Certain resources, depleted by the pressures of service provision, may be replenished by a training culture: exhibiting synergy rather than antagonism.

A Systems map was created to highlight boundaries, inter-dependence, and unequal power distribution: the challenges of LTFT and divided loyalties were described. Although not comprehensively explored, external (often legal) constraints further complicate this. Other sources of tension include the challenge of delivering high quality patient care when meeting educational and contractual mandates, with continuity of care being so particularly hard to achieve.

Key messages

1. If handled sensitively, the system could operate in a state of balance not direct conflict. ‘Training and service delivery are two strands of the same double-helix running through the Trust’. Similarly the value of a training culture was highlighted when done well: ‘service provision IS training’.

2. Feedback needs to be timely and high-resolution (both when training and when operating the Trust). Out of hours learning needs accurate feedback to maximize patient safety and exploit learning opportunities.

3. Less Than Full Time places demands on the system but flexibility needs to be embraced, particularly in training programmes.

4. The use of AHPs (non-Drs) to fill rotas is generally helpful, inevitable and progressive. However the competition for training opportunities requires close monitoring lest training suffers.

5. Lack of continuity of care is both a macro- and micro-challenge; it may threaten both high-quality and efficient patient care as well as good training.