The Francis and Keogh reviews have made junior doctors powerful agents for change

Francis report

The Francis report made four key recommendations for trainee doctors1:

• Trainee surveys should be optimised as a source of information about patient safety

• Trainees should be encouraged to be open, and they should be given protection to allow this

• Training inspections should obtain information from trainees to disseminate good practice

• Numbers of staff should be sufficient for proper training.

In our work with frail, vulnerable, older patients, we would add two further recommendations:

• Listen to patients, carers, and relatives. Do not be afraid to discuss their concerns, and yours, with consultants and management

• Set a good example, and take every opportunity to ensure frail and older patients have food and drink within easy reach and can use a call bell.

Keogh report

The Keogh report emphasises the importance in the NHS of putting patients first.2 The challenge for junior doctors is not merely to report problems in patient care and training, but also to take an active role in improvement—not just to do the job, but also to improve the job. Junior doctors should not only be professional and competent, but should also be activist professionals, driven by a social conscience to improve the NHS.45

In the past, innovations such as electronic discharge summary systems were introduced without consultation with junior doctors, the likely main users of such systems. Similarly, grand rounds and mortality and morbidity meetings have traditionally been dominated by consultants and discussion of unusual diagnoses, rather than the common practical issues of concern to junior doctors, such as symptom control, communication with relatives, and appropriate specialist referral.

Promote junior doctors’ contributions

Junior doctors are less likely than their senior colleagues to be desensitised to poor standards, however, and because they move frequently from hospital to hospital they are able to make valid comparisons.

Over the past 30 years, the time allocated for formal group teaching of junior doctors has increased, with a much more defined curriculum, but the opportunities available for team learning alongside consultants, nurses, and therapists have gradually diminished. Junior doctors contribute much more if they feel part of a clinical team.

Consultants, especially clinical supervisors, have a responsibility to encourage and facilitate junior colleagues to develop leadership skills. Rather than feel disenfranchised, as we did, junior doctors should be urged to have an increased role in management and departmental meetings.

An excellent opportunity to promote the contribution that junior doctors can make is at induction or during foundation doctor shadowing. We recommend that four key messages be conveyed to junior doctors at inductions:

• Be patient centred, and always put the patient first

• Speak up, and get to know your managers and hospital incident reporting system

• Set the right example—nutrition, hydration, and patients’ dignity are everyone’s responsibility

• Be a clinical leader, and get involved in service improvement, not just audit.

The Keogh review encourages junior doctors “not just to be clinical leaders of tomorrow, but also clinical leaders of today.”2 Junior doctors face a considerable challenge laid down in the Francis and Keogh reports to be positive agents for change in the NHS. Consultants and managers have an even greater challenge in creating the right environment for change to be supported and maintained.