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

Authors: Craig Winthrop, Iain Wilkinson, James George 

Publication date:  28 Oct 2013

The Francis and Keogh reviews emphasised the important role that junior doctors have in improving care in the health service. Craig Winthrop, Iain Wilkinson, and James George reflect on what has changed for junior doctors in the wake of the reviews

The potential of junior doctors to act as powerful agents of change to improve the quality and safety of care in the NHS has been highlighted in two recent reports. The report of Robert Francis’s inquiry into failings at Mid Staffordshire NHS Foundation Trust said that junior doctors are the “eyes and ears” of the NHS.[1] Bruce Keogh’s review of hospital trusts with higher than expected death rates said that the energy of junior doctors “should be tapped, not sapped.”[2] In addition, in both Tameside[3] and Stafford,[1] junior doctors’ concerns were early warning signs of serious underlying hospital problems.

As three doctors who qualified at different times (Craig Winthrop in 2012, Iain Wilkinson in 2004, and James George in 1977), we went through very different training systems. We recently joined forces to contribute to the 2013 foundation doctor induction and shadowing programme, and this led us to reflect on what has changed for junior doctors since the Francis and Keogh reviews, and how we can encourage junior doctors to make the most of the opportunities now available to them.

We do not believe the job of the junior doctor has become any easier. Although junior doctors no longer work excessive hours, they instead have to cope with an increased intensity of work, greater public scrutiny, and high expectations, which create different pressures.

Francis report

The Francis report made four key recommendations for trainee doctors[1]:

  • 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.[4] [5]

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.

Competing interests: We have read and understood the BMJ Group policy on declaration of interests and we have no relevant interests to declare.


  1. Francis R. Report of the Mid Staffordshire NHS Foundation Trust public inquiry. 2013. [Link] .
  2. Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts in England: an overview report. 2013. [Link] .
  3. Campbell D. Tameside Hospital: long waits, few staff, overcrowding. Guardian   2013 July 2.
  4. Castellani B, Hafferty F. The complexities of medical professionalism. In: Wear D, Aultman JM. Professionalism in medicine: critical perspectives. Springer, 2006.
  5. Health Foundation. Involving junior doctors in quality improvement. Health Foundation, 2011.

Craig Winthrop foundation doctor  North Cumbria University Hospitals Trust, Cumberland Infirmary, Carlisle
Iain Wilkinson specialty trainee 6 doctor  Kingston Hospital NHS Foundation Trust, Kingston upon Thames, Surrey
James George consultant physician  North Cumbria University Hospitals Trust, Cumberland Infirmary, Carlisle

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