The Return of the Firm: A Firm-Based Approach to the Modern Geriatric Ward

Introduction
The traditional 'firm' system, a team-based, apprenticeship model of care, was largely abandoned by 2009 following Modernising Medical Careers (2005) and the European Working Time Directive (2009). These reforms reduced resident doctors' continuous ward presence and increased team transience. At Stoke Mandeville Hospital, the GMC and local trainee surveys highlighted resident doctor dissatisfaction with continuity of care, training experience, and working environment. We piloted a reintroduction of the firm-based model to address these concerns.

Method
The geriatric medicine department was restructured into three teams, each comprising resident doctors led by two named consultants and allocated to a specific ward. Resident doctors were surveyed before and after implementation, assessing their perceptions of continuity of care, workload/efficiency, and quality of patient care.

Results
Pre-implementation, 83.4% of resident doctors disagreed or strongly disagreed that continuity of care existed, and 67% felt this increased inefficiency and workload. Following the change, 50% of residents reported positively that they believed their was continuity of staffing, with a 50% reduction in those attributing inefficiency and workload to the staffing model. Despite no change in staffing numbers, residents reporting that staffing enabled good patient care increased.

Conclusions
Reintroducing a firm-based structure improved resident doctors' perceptions of continuity of care, workload, and their ability to deliver good patient care, without increasing staffing resource. The pilot will continue, with future focus on educational outcomes, aligning educational and clinical supervisors with residents' own teams. We also plan to consider a Consultant of the Week model to further embed continuity.