​The NHS is under increasing pressure. Doctors are undertaking more complex and intense work, with the BMA's tracker survey showing that 44% of consultants find their workload unmanageable.

Against the backdrop of increasing systemic pressure, the GMC, NHS, and of course patients, have appropriately high expectations of consultants.

This guidance will help you:

• understand when and how you should be documenting risks and concerns
• to raise concerns openly, promptly and safely if you think that patient safety, dignity or comfort may be seriously compromised
• take different steps depending on the urgency of the situation, which may sometimes require a more rapid escalation

Recognising that consultants are working in a system under extreme pressure, it remains important that consultants continue to work with management colleagues to put solutions in place.

Steps to take if a service is becoming unsafe

It is important that at each stage you must document the practical steps you have taken when dealing with a service under pressure in a way that:

• ensures that your suggestions, recommendations and actions are seen where they need to be seen
• confirms that your employer shares the recorded responsibility for the way the service is forced to operate, and for the outcomes it delivers.

Although this guidance has progressive steps, if the situation dictates, it may be appropriate to contact your duty medical director as a first step.

1. Raise and document (via an incident reporting system such as DATIX) your safety concerns with the duty manager
2. Put in place any mitigation that you can reasonably undertake within the resources and authority that you have, and inform the duty manager
3. Inform the duty manager if mitigations are likely to be temporary, such as additional duties being asked of existing staff or reallocation of staff from other less urgent duties
4. Some employing organisations have useful relevant policies that you can refer to e.g. policies regarding locums or out of hours cover, which can be activated during working hours
5. Seek urgent support for more sustainable solutions or extension (if appropriate) of the immediate / interim actions taken, and:

• with management, consider whether colleagues in other units can curtail elective work to support the service
• establish when and how you will be kept informed of what support is put in place
• continue to work with your management structure when potential solutions are suggested.

If nothing happens when you have raised a concern

If there has been no resolution and/or site manager support is not providing effective assistance, contact the next most senior clinical manager available.

Out of hours there may be a hierarchy of management to approach in order, such as a duty medical director, duty senior manager and/or an on-call director.

Where concerns persist and/or support has been inadequate or ineffective, escalate your concerns (referencing actions taken and appropriate advice) to the duty medical director.

Closing the service

Where there is an immediate threat to patient safety which cannot be resolved by other methods it may be appropriate to close a service to new patients and for them to be diverted to other units/services while your service’s situation is resolved and safety re-established.

If that recommendation is called for, you should provide the rationale and a written record as soon as practicable. Such decisions should be made in discussion with a senior director/medical director.

It is likely that authority to close or suspend a service will be at senior director or CEO level and not with an individual consultant. However, consultants do have a responsibility to consider, and make, such a recommendation to preserve patient safety.

Communicating risk to other organisations

Where immediate support through the management structure does not address the concerns you raise, you should explain that you are continuing to provide care to the best of your ability.

This is under circumstances that your employer has failed to address, despite your interventions, and the employer will carry responsibility should there be adverse outcomes.

1. Follow up your earlier actions, particularly where concerns persist and/or support has been inadequate or ineffective, in writing to your medical director.
2. Copy in, where appropriate, your medical advisory structures and LNC.
3. Focus your email/letter on fact, being accurate and informative, referencing actions taken and appropriate advice.
4. Consider contacting your medical defence organisation for advice.
5. Consider the option to raise your concerns via your employer’s whistleblowing mechanisms or via your employer's freedom to speak up guardian.

Where you have taken all appropriate escalation and intervention actions yet concerns persist and/or support has been inadequate, consider informing the chair of the board and/or non-executive directors of your safety concerns.

1. Consider involving your LNC officers as part of this.
2. Consider taking the advice of your MDO.
3. Be specific, factual and accurate, with as much appropriate information as possible.
4. Consider informing the CQC of your concerns on the next working day and, if you do so, document your interaction.

​In an acute situation it may be difficult to undertake a number of these steps whilst still providing care. It is advisable for senior doctors to consider the possible options to mitigate problems in advance, as a team, and preferably with an action plan for such events.

Your responsibility to protect your colleagues

The GMC has issued guidance appropriately reaffirming that junior doctors should never be in unsupervised and unsafe clinical environments.

They are encouraged to raise their patient safety concerns immediately with the senior clinicians they are working with, or with their educational supervisor or deanery. Consultants have a responsibility:

• to monitor the safe working of the wider clinical team
• to ensure that those concerns are listened to, documented appropriately, and taken seriously – including further reporting when not resolved locally
• to be available and approachable so that juniors feel able to raise their concerns with them, during out of hours periods
• for junior doctors training and must ensure they know clearly who they should report their concerns to
• to conduct a debrief with your whole team as soon after an event as is safe to do so and to provide relevant support following a significant event. The format of that debrief should be agreed locally. You may consider it best for that debrief to be un-minuted and not include documented reflective practice
• to know your medical teams – and during each shift: know there is a full complement of members and know who they are
• be able to make an informed judgement about whether the team is able to deliver the care expected of them
• be informed of changes to anticipated workload and be able to match the available resources to the expected clinical demand
• have adequate job planned time for handover.

How to document concerns

1. Consider carefully the correct tool or mechanism to record or raise a concern
2. Add context by carefully recording systems pressures and contributory factors
3. Re-read all content aware that it could be read without ambiguity or inappropriate blame by a third party - ensure that it is factually accurate
4. Record the name and role title of the managerial personnel you have spoken to
5. It may be that some of these conversations will need to be repeated, or held with other managerial personnel - they may require witnesses
6. DATIX incident reporting (or equivalent) should be undertaken, and formal concerns raised in writing, where necessary
7. Follow up face-to-face or phone conversations with emails detailing what you have discussed, copying in the Trust medical director and senior on-call Trust director.

The responsibility of your employer

• Responsibility for putting in place mitigating actions to deal with a potentially unsafe service ultimately rests with your employing organisation
• The consultant is responsible for making an initial judgement regarding clinical safety
• The employer must take responsibility for putting in place measures to ensure safe care is provided
• The employer must listen to the experienced clinical judgement of its senior doctor
• Management colleagues also have a responsibility to promote an open and tolerant culture where concerns can be raised without fear of intimidation or any form of bullying