ABSTRACT
In 2018, North Bristol Trust (NBT) faced difficulties recruiting clinical fellows. In response, a new programme was introduced that includes opportunities for non-clinical time, supervision, and a study budget, as well as flexibility of contract duration and on-call commitment. This has significantly improved the application ratios, with a 94% fill rate in August 2021 and competition ratios of 2.5:1. Not only has it been successful for staffing medical rotas, but clinical fellows also report positive experiences, have gained opportunities that would not be available in a training role and feel the role will benefit their future job applications. This report outlines the new programme and analyses it from the clinical fellow and Trust perspective. We hope that by sharing this successful new programme, other organisations can take inspiration to harness the potential of the high proportion of doctors taking a break from training post-foundation programme.
Introduction
In 2018 North Bristol Trust (NBT), like many hospitals around the country, faced difficulties recruiting doctors to their locally employed doctor (LED) roles. Despite being a large teaching hospital with 1,000 inpatient beds, NBT filled only 6 of 16 available medical LED posts by August 2018. This equated to a potential cost of £284,220 over the year based on NBT locum rates if all out-of-hours gaps were staffed. Rota gaps are well documented to have a detrimental impact on staff morale, patient safety and trainee learning opportunities.1 Existing clinical fellow posts were clearly not sufficiently attractive to the desired applicant.
The low application rate could not be attributed to a lack of potential applicants. Taking time out of training after foundation year 2 (F2) has gone from being the exception to the norm. The General Medical Council (GMC)'s 2017 survey2 showed that 54% of F2 doctors take a break immediately after completing the Foundation Programme – a 24% increase from 4 years previously – and the proportion has increased further since.3 The consistent reasons for taking a break were work/life balance, burnout and wanting to gain further experience before making a speciality decision. This report on the new medical clinical fellow posts at NBT illustrates how it is possible to balance the pressing short-term goals of safe staffing levels with the long-term benefit of investment in post-F2 doctors as future trainees.
Solution
A new medical clinical fellow post was introduced in 2019. It was designed by the chief registrar to be more attractive by providing a more flexible, educationally rich programme aiming to increase applications to these LED posts, thus reducing costly rota gaps. In its design phase other existing programmes were studied, including posts at Brighton and Sussex,4 which offered emergency medicine posts with 25–33% non-clinical educational time, a study budget and flexible working time, and Nottingham posts5 offering flexible contract durations with options for paid employment breaks and 10% non-clinical time. North Bristol's new clinical fellow posts build in elements of both programmes. They are structured around fellows' specialty preferences and contract duration with options for planned unpaid leave and offer 20% professional development time to those with contracts of 6–12 months. This 20% time can be used at the fellow's discretion for educational activities, projects and to build their portfolio, with support from educational and clinical supervisors plus the use of a £500 study budget. Supervisors are funded by NBT at parity with trainee supervision and are resourced from the participating departments. On-calls are optional and at a lower frequency than in a standard training role and provide exposure to acute medicine and the medical take.
With the third cohort of doctors currently in post, we analysed the success of the post from the perspectives of the Trust and clinical fellows, including tracking fill rates, competition ratios, and surveying consultants and clinical fellows. All clinical fellows in posts in spring 2021 were emailed a mixed qualitative and quantitative incentivised (with a retail voucher prize draw) online survey which was distributed twice at a 6-week interval to maximise response rates achieving a response rate of 20 of 33 2020–2021 fellows. All incoming 2021–2022 fellows were surveyed on their reasons for applying to the post, with 100% response rate. The surveys were drawn up with focus group discussions including the clinical fellow consultant lead, the chief registrar who established the programme and current clinical fellows to ensure clarity and relevance.
Outcome
The introduction of the new clinical fellow post has achieved the intended outcome from the Trust's perspective. The fill rates of these posts in August each year went from 6 of 16 (37.5%) prior to intervention to 21 of 22 (95.5%) in 2019, 31 of 33 (91.2%) in 2020 and 32 of 34 (94.1%) in 2021. In 2021, the competition ratio for a post was 2.5 applicants per post. Fill rates over the last 2 years are illustrated in Fig 1. Departmental consultant leads were surveyed in 2020 about working with clinical fellows. Their feedback was largely positive, with qualitative feedback including ‘we're utterly dependent [on clinical fellows]’ and that fellows were ‘stable and predictable’. Negative feedback included that 20% non-clinical time was disruptive to rostering and that the focus of clinical fellows' professional development activities did not always align with departmental objectives.
Clinical fellow fill rate by month.
From a clinical fellow perspective, motivations for taking a LED role at NBT echoed the national picture of an intentional move away from training jobs after F2. Only two doctors in 2020–2021 and three doctors in 2021–2022 cohorts stated that they took the post because they did not achieve a desirable training post. The most common reasons for the 2020–2021 cohort wanting to take this post were ‘job location’ (82%), ‘to help to decide career plan’ (73%) and ‘to further develop clinical knowledge prior to training’ (55%). For the 2021–2022 group, reasons included ‘to build experience in quality improvement/ audit/ research’ (90%), ‘to further develop clinical knowledge prior to training’ (88%), and ‘to help decide career plan’ (79%).
Of the 2020 cohort, 90% reported their overall experience was ‘good’ or ‘very good’ and 100% said they would recommend the post to F2 doctors. All respondents agreed that ‘the role was/will be beneficial in my future applications' with comments including ‘I have managed to boost my CV exponentially’ and ‘a happier, more point rich, better rested, well rounded and interested applicant I will be’. All but one respondent agreed that ‘the non-clinical time has given me opportunities that would not be available during a training role’. The professional development activities undertaken are illustrated in Fig 2; examples include developing a simulation on-call teaching programme for medical students and writing the Trust guideline for the inpatient management of Parkinson's disease. Negative feedback included poor rota planning, lack of clarity about expectations from professional development time and difficulty scheduling this time, with fellows reporting 17% of their professional development time was filled with clinical work. Fellows found this time was more reliably protected when it was scheduled into the rota.
Non-clinical activities, 2021–21 cohort.
Conclusion and discussion
Medical workforces have been increasingly under pressure, with more doctors than ever taking breaks from NHS work or leaving medicine altogether. Attracting the post-F2 cohort has never been more important to provide consistent safe staffing while offering valued clinical training. This article discusses a new, carefully designed clinical fellow post at North Bristol NHS Trust, illustrating the benefits for both the Trust, with significantly improved fill rates, and the clinical fellows themselves. Feedback demonstrates the posts are attractive, enjoyable, beneficial for career progression and offer a welcome break from the pressures of training. By investing in this group of doctors – providing a study budget, supervision, and professional development time – the Trust is directly investing in the future medical workforce. More broadly, opportunities for such doctors can have great benefits including recovery from burnout and re-alignment of personal and professional goals.6
The main drawback of the programme to the Trust is one of the things that makes it attractive to applicants: the contract flexibility. Doctors choosing less than 12-month contracts and terminating contracts early is problematic for rota planning and requires several cycles of recruitment throughout the calendar year, resulting in reduced fill rates through the summer months. Developing closer supervision for 20% professional development time is in progress, aiming to maximise what doctors can achieve for themselves as well as for the department or trust. An annual awards ceremony has been introduced celebrating achievements in professional development activities and increasing project sustainability by handing projects over to incoming fellows. While it has been argued that 20% professional development time can be disruptive to continuity of care, the increasing number of doctors working less than full time and the introduction of personal development time to trainee contracts means that rota flexibility is essential. We hope by sharing this new programme other hospitals can create attractive LED posts that work for organisations and individuals.
- © Royal College of Physicians 2023. All rights reserved.
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