Introduction As a Darzi Fellow in a London mental health trust, my challenge entails a review of medical rotas for junior doctors (JDs), which are suboptimal and problematic. The challenges of service transformation, growing complex clinical needs, staffing levels, and patient safety all feed into this challenge. There is a drive for positive change alongside collaborative approaches to ensure stakeholder buy-in for sustainable change.

Medical rotas and staffing had not been reviewed, despite considerable changes in acuity and service configuration resulting in workload variation across sites

Concerns around work intensity, patient safety, and staff wellbeing arose, compounded by limited numbers of JDs on-call.

The rota review will address this by changing rota patterns and staffing across two busiest sites, improving adherence with JD contractual requirements, and optimising patient safety and flow to accommodate growth and demand.

Aims and objectives of the research project or activity Collaboration and scoping of concerns through stakeholder mapping required engagement with doctors and others impacted: ward staff, consultants, site leads, and Approved Mental Health Practitioners.

An options appraisal (including fact sheets to mitigate concerns) was drafted and financial implications explored. All options were discussed with stakeholders, prior to approval by Training Programme Directors (TPDs), the Director of Medical Education (DME), and Trust Board.

Codesign of proposals with stakeholders, especially JDs, was pivotal for buy-in and insight from staff working shifts.

Method or approach This review intends to improve the structure of the medical rotas, equity of workload distribution, JDs’ wellbeing (through a sense of co-designing of change), and retention and recruitment. These changes should benefit patient flow and patient safety as doctors work in better staffed environments, improving care.

Complexity of medical rotas is not specific to this Trust. A neighbouring organisation has already asked us to share our learning and we anticipate that others can learn from our approach.

Barriers to implementation include resistance to changes in structures, and conflicting priorities of stakeholders. Joint leadership across operational directors who hold responsibility for budgets and service safety and effectiveness may be needed, including the medical directorate responsible for leadership and postgraduate education of doctors. Split responsibility may have contributed to failures to address these challenges.

Medical rotas are contentious, and stakeholders had competing priorities and varying views.

We took a whole system view and invested time in defining problems through iterative enquiry, compromise, and understanding concerns rather than racing to quick solutions that didn’t address problems sustainably.

Leadership styles and approaches to change work are a core focus on the Darzi programme, and informed our approach.

JDs and JD representatives, finance, human resources, rota coordinators, TPDs, DMEs, heads of service, and board members engaged in the review.

The JDs’ Contract, Health Education England code of practice, and the trusts’ standard operating procedures were complied to.

Positive practice from neighbouring organisations were also examined.

Findings There are recurring themes in our approach to complex problems in the NHS and lessons to be learned through how we approach problems, collaborate with neighbouring Trusts, and coproduce solutions that have buy-in from stakeholders.

In healthcare, we tend to work in siloes rather than collectively, and there can be top-down pressures to implement rapid solutions that may unsustainable, and through their incautious rapidity are likely to produce unintended consequences.

Effectiveness will be measured quantitively through rota fill-rates, locum usage, bank shifts fill-rate, national training survey feedback, and rates of contractual exception reporting; considering the confounders that can impact these matrices. Qualitatively, there will be engagement with established forums, and staff feedback will consider impacts on workload for other staff groups and patient flow.

The redesign may not solve the matter of high workload pressures and further change may need to be explored, especially with continued rises in acuity.

Proposed rota changes have been approved for implementation in February 2024.

There will be a review in six-months to assess how the changes affect adherence to contractual breaks, equilibration of workload across sites, and effects on higher grade doctors’ workload.

This will feed into decisions about staffing and financial considerations.

Key messages JDs are essential workforce and out-of-hours rotas are a common area of concern despite profoundly affecting job satisfaction and care delivery.

Collaborative reviews of rotas should be normalised, and lessons learned shared across Trusts to improve practice and doctors’ experiences irrespective of their rotation. We hope to encourage sustainable approaches benefitting services and staff.