Return of the “firm” gets cautious welcome

Authors: Abi Rimmer 

Publication date:  06 Dec 2016

Jeremy Hunt’s proposal to the NHS Providers conference[1] is broadly supported, but doctors point out that the world has moved on as shift patterns and working hours have changed. Abi Rimmer reports

Among a range of initiatives announced last week as part of work to improve junior doctors’ morale was a plan to reintroduce the medical “firm” system.

Speaking at the NHS Providers annual conference, Jeremy Hunt, England’s health secretary, said that by dismantling the firm system when doctors’ working hours were reduced “we may have thrown the baby out with the bathwater.” He asked, “Can we bring back the firm or at least the best bits of it?”[1]

Hunt said that Health Education England would work with the Royal College of Surgeons, teaching hospitals, and education providers to explore whether a modern firm structure could enhance medical teams and make junior doctors feel more valued.

“This pilot will take the best parts of the traditional ‘firm’ into the modern hospital,” he said. With an emphasis on multidisciplinary learning and longer placements for trainees, the aim of the pilots was “to allow for more meaningful relationships to improve training and supervision and foster a genuine sense of mentorship,” he said.

Need for inclusion

Richard Montgomery, honorary treasurer of the Royal College of Surgeons of Edinburgh, said that the introduction of a modern firm structure that included all members of the multidisciplinary surgical team could help to make junior doctors feel more valued.

“Nowadays the surgical team incorporates a lot more nurses with special skills and professions allied to medicine, so the surgical team is a much broader based item,” he said. “What we would like to do is to get the more junior doctors feeling like they are an integral part of this rather than being somebody who’s just being used to plug gaps in rotas and doesn’t really feel part of a team.”

Jane Dacre, president of the Royal College of Physicians, said that she welcomed the plan—in principle. “There is a lot of evidence that trainees at the moment feel that they are not properly supported in their work in the hospital, and anything that brings in a better social network for them—people to talk to, people to ask a question of—is likely to improve their morale. Whether we can turn back the clock to how it was 20 or 30 years ago is probably more difficult.”

The college’s registrar, Andrew Goddard, said that it was important not to try to replicate the firm structures of the past. “We know there aren’t enough doctors to go back to the old firm of consultant, senior registrar, registrar, senior house officer, and houseman,” he said.

“We must be careful that we don’t aim for something that is unachievable. We have to build a team that is fit for the NHS. The modern team is going to include (as well as doctors) nurses, advanced care practitioners, and physician associates. So the new firm has to acknowledge the part that all of those health professionals can play.”

No return to old system

Jeeves Wijesuriya, joint deputy chair of the BMA’s Junior Doctors Committee, said that plans to bring back the firm “indicate an acknowledgment of some of the issues that juniors have been talking about.” But he said that it would be a mistake to want a return to a system that was based on old ways of working, with doctors putting in extremely long hours.

“When Hunt talks about firms, what I hope he is referring to is the sense of community, the sense of mentorship that trainees should experience with the people training them. And the ability to work with people for more than just a transient period—people who invest in your training, people who invest in your career progression and who take on the roles of mentors,” he said.

“That is the kind of thing that I think trainees want to see. So ‘firm’ isn’t really the best term: we want to see some of its aspects while maintaining the things that we have put in to protect against the damaging aspects of the old firm system.”

Clare Gerada, medical director at the NHS Practitioner Health Programme, said that the announcement was a sign that Hunt was listening to the profession and represented a positive change for many trainees who currently felt isolated. “One of the problems we have got with the current NHS is that junior doctors feel like itinerant workers. What we’ve lost is the relationship between teams and, in particular, medical teams,” she said. “We’ve created a whole series of isolated doctors and even senior doctors identify juniors by their position and not their name.”


  1. Department of Health. Hunt J. NHS Providers annual conference keynote speech. 30 Nov 2016. [Link] .

Abi Rimmer BMJ Careers

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