Introduction

The vital role of medical workforce well-being for improving patient experience and population health while assuring safety and reducing costs is recognised internationally. Yet the persistence of poor well-being outcomes suggests that current support initiatives are suboptimal. The aim of this research study was to work with, and learn from, diverse hospital settings to understand how to optimise strategies to improve doctors’ well-being and reduce negative impacts on the workforce and patient care.

Methods

Realist evaluation consistent with the Realist And Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) II quality standards. Realist interviews (n=124) with doctors, well-being intervention implementers/practitioners and leaders in eight hospital settings (England) were analysed using realist logic.

Results

There were four key findings, underpinned by 21 context-mechanism-outcome configurations: (1) solutions needed to align with problems, to support doctor well-being and avoid harm to doctors; (2) doctors needed to be involved in creating solutions to their well-being problems; (3) doctors often did not know what support was available to help them with well-being problems and (4) there were physical and psychological barriers to accessing well-being support.

Discussion and conclusion

Doctors are mandated to ‘first, do no harm’ to their patients, and the same consideration should be extended to doctors themselves. Since doctors can be harmed by poorly designed or implemented well-being interventions, new approaches need careful planning and evaluation. Our research identified many ineffective or harmful interventions that could be stopped. The findings are likely transferable to other settings and countries, given the realist approach leading to principles and causal explanations.

Background

Over the past two decades, the UK has actively developed policies to enhance early cancer diagnosis, particularly for individuals with non-specific cancer symptoms. Non-specific symptom (NSS) pathways were piloted and then implemented in 2015 to address delays in referral and diagnosis. The aim of this study was to outline the functions that enable NSS teams to investigate cancer and other diagnoses for patients with NSSs.

Methods

The analysis was derived from a multisite ethnographic study conducted between 2020 and 2023 across four major National Health Service (NHS) trusts. Data collection encompassed observations, patient shadowing, interviews with clinicians and patients (n=54) and gathered documents. We used principles of the functional resonance analysis method to identify the functions of the NSS pathway and analyse their relevance to patient safety.

Results

Our analysis produced 29 distinct functions within NSS pathways, organised into two clusters: pretesting assessment and information gathering, and post-testing interpretation and management. Safety-critical functions encompassed assessing the reason for referral, deciding on a plan of investigation and estimating the remaining cancer risk. We also identified ways that teams build and maintain safety across all functions, for example, by cultivating generalist-specialist expertise within the team and creating continuity through patient navigation. Variation in practice across sites revealed targets for an NSS pathway blueprint that would foster local development and quality improvement.

Conclusions

Our findings suggest that national and local improvement plans could differentiate specific policies to reduce unwarranted variation and support adaptive variation that facilitates the delivery of safe care within the local context. Enhancing multidisciplinary teams with additional consultants and deploying patient navigators with clinical backgrounds could improve safety within NSS pathways. Future research should investigate different models of generalist-specialist team composition.

Objective

To estimate and quantify the cost implications and health impacts of improving the performance of English endoscopy services to the optimum quality as defined by postcolonoscopy colorectal cancer (PCCRC) rates.

Design

A semi-Markov state-transition model was constructed, following the logical treatment pathway of individuals who could potentially undergo a diagnostic colonoscopy. The model consisted of three identical arms, each representing a high, middle or low-performing trust’s endoscopy service, defined by PCCRC rates. A cohort of 40-year-old individuals was simulated in each arm of the model. The model’s time horizon was when the cohort reached 90 years of age and the total costs and quality-adjusted life-years (QALYs) were calculated for all trusts. Scenario and sensitivity analyses were also conducted.

Results

A 40-year-old individual gains 0.0006 QALYs and savings of £6.75 over the model lifetime by attending a high-performing trust compared with attending a middle-performing trust and gains 0.0012 QALYs and savings of £14.64 compared with attending a low-performing trust. For the population of England aged between 40 and 86, if all low and middle-performing trusts were improved to the level of a high-performing trust, QALY gains of 14 044 and cost savings of £249 311 295 are possible. Higher quality trusts dominated lower quality trusts; any improvement in the PCCRC rate was cost-effective.

Conclusion

Improving the quality of endoscopy services would lead to QALY gains among the population, in addition to cost savings to the healthcare provider. If all middle and low-performing trusts were improved to the level of a high-performing trust, our results estimate that the English National Health Service would save approximately £5 million per year.

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