Beyond the basics: how to fix the medical ward round

During 35 years working in the NHS, Dr Rajendra Kumar Sinha witnessed a gradual decline in the support and organisation of medical ward rounds. Physicians, he argues, seem to have given up on ward rounds, and have accepted this decline as ‘the norm’ in their day-to-day working lives. Here he outlines some of the steps the NHS should take to repair the situation.

Doctors have stopped expressing concerns about medical ward rounds, as they find it easier to get on with them rather than fighting the system. Ward rounds in medicine: principles for best practice, the 2012 joint publication from the RCP and the RCN, has to be regarded as a landmark. At that point, many physicians, including me, were delighted that at last there was recognition of this important matter at the highest level, and I was hopeful the situation would improve. Unfortunately, the initial hope for improvement has died out over subsequent years.

In recent years, repeated internal surveys of medical consultants’ ward rounds in my trust hospital revealed that standards fell well short of the best practice recommended by the RCP and RCN. In the absence of a formal nationwide survey of medical ward rounds, it is difficult to be certain, but I suspect the situation would be similar in other NHS hospitals. This view is certainly supported by my personal discussions with many other colleagues.

As the harmful effects to patients may not appear until later, it is often hard, if not impossible, to link them to the shortcomings of poorly supported and poorly organised ward rounds.

Dr Rajendra Kumar Sinha

As the harmful effects to patients may not appear until later, it is often hard, if not impossible, to link them to the shortcomings of poorly supported and poorly organised ward rounds. In addition, there is currently no reliable tool for evaluating this either. Therefore, it is unsurprising that this matter has failed to draw the attention of hospital managers, commissioners and regulators.

The absence of nurses and junior doctors, inability to readily access results of investigations and repeated disruptions on a noisy ward are frequent occurrences during a physician’s ward round. Benefits of a well-organised and supported medical ward round, listed by the two royal colleges, include:

  • improvement in care, safety and experience of patients
  • better patient flow
  • more efficient use of resources
  • improvement in satisfaction and training of medical staff.

In the current situation, not only might we be losing out on these benefits, we may also be unwittingly compromising patient safety and wasting resources. Clinical, legal, ethical and moral implications could be serious and far-reaching for clinicians if mishaps occurred as a result of working in such conditions. A similar scenario would be unthinkable and totally unacceptable if a surgeon had to operate without an assistant, the appropriate tools for surgery, a clean operating theatre, relevant scans and X-rays, and was working with frequent interruption.

‘Our way of working would not be accepted by businesses making decisions of far less impact than we, as healthcare professionals, make every day,’ noted Matt Morgan in his BMJ article 'The ward round is broken'

As such, an intense nationwide discussion is urgently needed among the medical profession and managers in the NHS. New initiatives at all levels are required, to raise the profile of medical ward rounds as a matter of central importance once again.

Dr Rajendra Kumar Sinha

The indications are that the guidance published by the two royal colleges is unlikely to have achieved its intended purpose and the call to ‘fix the broken ward round’ has not caught noticeable momentum as yet. As such, an intense nationwide discussion is urgently needed among the medical profession and managers in the NHS. New initiatives at all levels are required not only to raise the profile of medical ward rounds as a matter of central importance once again, but also to go beyond.

Gone are the days when a consultant’s concerns could be resolved simply by having a chat with the ward sister over a cup of coffee. Unfortunately, we now live in an era where even the very obvious has to first be proven by large-scale surveys and audits. The RCP and RCN are best-placed to commission a formal benchmarking exercise and identify why our ward rounds are in such a mess.

The challenge would then lie in knowing how to fix the problem. In his BMJ article 'Fixing the broken medical ward round is in everyone’s interests', Robin Baddeley argued that an economic benefit would prove the strongest incentive for fixing the broken medical ward round. Although it seems to be a sensible idea, the answer is likely to lie in a multipronged approach. Consolidating on the basics recommended by the RCP and RCN would increase the awareness of all concerned and change the work culture to create a sound base for change.

However, in the modern NHS the solution to such a deep-rooted problem will require additional measures, such as:

  • involving commissioners and providers as stakeholders in national guidelines
  • a requirement on part of the provider hospitals to put this matter high on their agenda, and place it on their risk register
  • a stipulated requirement for provider hospitals to meet standards of best practice recommended by the professional bodies, and commissioners to include this matter in service level agreement with provider hospitals
  • making the ward round an essential part of protocol for inspection by the Care Quality Commission
  • educating the general population about what to expect from a consultant’s ward round and empowering them to seek clarification if they suspected anything untoward with the process.

These suggestions could be some of the many measures to help improve the dire situation of the medical ward round.

Dr Rajendra Kumar Sinha worked for the NHS for 35 years, 22 of those as a consultant in general and respiratory medicine. He retired as a consultant physician in April 2017, having also been an honorary senior lecturer in medicine at the University of Bristol, a PACES examiner, and chair of the BMA local negotiating committee at his NHS trust.

This article features in the October issue of Commentary magazine.