The NHS is under increasing and unsustainable pressure, with A&E attendances, waiting times and admissions all on the rise in recent years. Doctors are also undertaking more complex and intense work, with the BMA's tracker survey showing that 44% of consultants now find their workload unmanageable.
Doctors are being asked to do more with less. Against the backdrop of increasing systemic pressure, the General Medical Council (GMC), the NHS, and of course patients, have appropriately high expectations of consultants (and those acting as responsible clinicians).
The following guidance will assist consultants in understanding their own responsibilities, and the responsibilities of managers, to their patients, their colleagues, and to themselves, within a working environment when it becomes unsafe. It will also help consultants understand when and how they should be documenting risks and concerns, and will help them to raise concerns openly, promptly and safely if they think that patient safety, dignity or comfort is, or may be, seriously compromised.
This guidance offers a graduated approach to guide you in how best to raise and escalate concerns. It outlines a variety of different steps which you can take depending on the seriousness and urgency of the situation, which may sometimes require a more rapid escalation.
While recognising that consultants are working in a system under extreme pressure, it remains important that consultants continue to work as collaboratively as possible with management colleagues to put in place constructive solutions, even while working under difficult and taxing circumstances.
Read the guidance (PDF)
What you should do if you think a service is becoming unsafe
At each stage you must document the practical steps you have taken when dealing with a service under pressure in a way that both ensures that your suggestions, recommendations and actions are seen where they need to be seen, and confirms that your employer shares the recorded responsibility for the way the service is forced to operate, and for the outcomes it delivers.
Although the guidance has progressive steps, if the situation dictates, it may be appropriate to contact your duty Medical Director (point 6) as a first step.
- Raise and document (via an incident reporting system such as DATIX) your safety concerns with the duty manager
- Put in place any mitigation that you can reasonably undertake within the resources and authority that you have, and inform the duty manager. Again, document this in your incident reporting system
- 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
- Some employing organisations have useful relevant policies that you can refer to eg policies regarding locums or out of hours cover, which can be activated during working hours
- 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. Document the action(s) in your incident reporting system
- 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. Document the action in your incident reporting system
- Where there is an immediate threat to patient safety which cannot be resolved by other methods it may be appropriate to close or suspend 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
- 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 under circumstances that your employer has failed to address, despite your interventions, and the employer will carry appropriate responsibility should there be adverse events or outcomes. Document the action in your incident reporting system
- Follow up your earlier actions, particularly where concerns persist and/or support has been inadequate or ineffective, in writing to your Medical Director; copying in, where appropriate, your Medical Advisory structures and LNC. Focus your email/letter on fact, being accurate and informative, referencing actions taken and appropriate advice
- Consider contacting your medical defence organisation (MDO) for advice
- Consider the options open to you to raise your concerns via your employing organisation’s whistleblowing mechanisms or via your employing authority’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, and:
- consider involving your LNC officers as part of this
- consider taking the advice of your MDO
- be specific, factual and accurate, with as much appropriate information as possible
- 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.
Recommending that a service is suspended or closed is a significant and sometimes difficult decision to take, having exhausted other options, and only in the interest of the safety of the service. However, it may be judged that ultimately, under such exceptionally difficult circumstances, it may be best to allow others – even given careful and proper consideration of how far away that alternate care might be - to provide care at a different location, until their own service can be made safe again.
It is likely that authority to close or suspend a service will reside 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.
The GMC has issued guidance appropriately reaffirming that junior doctors should never be exposed to 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. As such, consultants:
- Have a responsibility to monitor the safe working of the wider clinical team
- Have a responsibility to ensure that those concerns are listened to, documented appropriately, and taken seriously – including further reporting when not resolved locally
- Have a responsibility to continue to be available and approachable so that juniors feel able to raise their concerns with them, during out of hours periods
- Are responsible for junior doctors training and must ensure they know clearly who they should report their concerns to
- Should conduct a debrief with their team, including junior doctors, as soon after the 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
- Should, as far as practical, know their medical teams – and during each shift:
- know whether they have a full complement of members
- know who those team members 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
Consultants have a responsibility to junior doctors and other colleagues, including SAS doctors, to raise concerns when doctors are placed in potentially unsafe clinical environments, and take the appropriate escalatory steps as outlined.
Protecting yourself for the sake of patients
Deciding whether a service is safe or unsafe will be complex and stressful, particularly at exceptionally busy times. However, even under those pressures, it is vital that you document the relevant details – for instance concerns raised to you by junior doctors or other clinical staff, near misses, or discussions you have had with management colleagues where you have raised concerns about the safety of the service. When you record concerns and reflections on any aspect of patient care, including in those involved in recommending the closure of a unit, it is important to adhere to the following key principles:
- Consider carefully the correct tool or mechanism to record or raise a concern
- Contextualise critical content by carefully recording systems pressures and contributory factors
- 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
- Record the name and role title of the managerial personnel you have spoken to. It may be that some of these conversations will need to be repeated, or held with other managerial personnel. Such conversations may require witnesses, especially if there is resistance to following the advice of the consultant. DATIX incident reporting (or equivalent) should be undertaken, and formal concerns raised in writing, where necessary
- 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, to ensure that you have established a record of events while the details are still recent
The responsibility of the employing organisation
Responsibility for putting in place mitigating actions to deal with a service which is potentially becoming unsafe ultimately rests with the employing organisation. Although it is the consultant who rightly makes a judgement regarding clinical safety, the employer must take responsibility for putting in place measures to ensure safe care is provided, and for listening to the experienced clinical judgement of its senior doctors. 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.
The overriding principle is that the management structure of your employing organisation must embrace their responsibilities to you, your colleagues, and to patients for the service which they are operationally responsible.