SJT Textbook: Effective Use of Limited Resources
Effective Use of Limited Resources MSRA
This guide covers the crucial stewardship of Effective Use of Limited Resources MSRA scenarios. In the Professional Dilemmas paper, you must demonstrate the ability to be a guardian of NHS assets, understanding that “More” is not always “Better.”
🎥 Video Lesson (YouTube)
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FREQUENCY: Medium
PRIORITY: Must-Know
🎯 THE CORE PRINCIPLE
Effective use of limited resources means delivering safe, fair care with finite beds, staff, time and diagnostics. You start from the clinical question, choose investigations and treatments that will actually change management, avoid unnecessary repetition, and coordinate with pharmacy, radiology and flow teams.
This matters because over-ordering, duplication and last-minute discharge work create avoidable delays, crowding and harm. Patients in ED wait longer, time-critical treatments are postponed, and exposure to radiation or contrast may be unjustified. The SJT tests whether you act as a responsible steward: picking clinically appropriate, cost-conscious options while never letting resource constraints excuse unsafe care.
High-scoring options link every request to a clear management decision, check existing results, pick the least burdensome equivalent, start discharge planning early, and document constraints and escalation when capacity risks become unsafe or unfair. Low-scoring options lean on “just in case” testing, repeating normal scans, starting TTOs at 17:00, or silently queuing patients without documenting or escalating risks.
⚡ HIGH-YIELD ACTIONS (What Scores Points)
1. Start with a clear clinical question and order only tests that will change diagnosis, treatment or disposition.
2. Check prior results and imaging before re-ordering; repeat only when clinically justified (deterioration, expiry, poor quality).
3. Choose the least burdensome, clinically equivalent option (for example, ultrasound instead of CT where appropriate and safe).
4. Plan discharges and flow early in the day: start TTOs, therapy referrals and transport requests well before the afternoon rush.
5. Coordinate with pharmacy, radiology, bed management and therapy to use scarce slots and booking windows wisely.
6. Record resource constraints, delays and their impact in the notes; include safety-net advice and review timings.
7. Escalate to seniors and site/ops when resource limits risk patient harm or inequity, and propose practical solutions.
8. Use BRAN (Benefits, Risks, Alternatives, do Nothing) when discussing investigations and treatments to support shared decisions and reduce overuse.
* Repeated high-radiation imaging “to be thorough” despite recent normal studies and no change in clinical status.
* Discharges consistently started late in the day, blocking beds and worsening ED crowding.
* Pharmacy or therapy bottlenecks known but not discussed with site/bed management, leading to unsafe delays.
* Resource constraints (for example, no HDU beds, full CT list) not documented or escalated, leaving decisions opaque and unfair.
* Pressure to cut tests or discharge early without consideration of clinical risk, BRAN, or shared decision making.
In general, traps either overuse high-cost/high-burden resources without benefit or under-react to dangerous constraints by staying silent and unplanned.
💬 MODEL PHRASES (Use These in SJT Logic)
* “Pharmacy and site: we have three planned discharges today; starting TTOs now with a target of 14:00, and requesting porters and transport early.”
* “The CT list is full; an urgent ultrasound today will answer the clinical question safely. If the patient deteriorates, I will escalate to the on-call consultant and site manager.”
* “I have documented the capacity constraints, the plan we have agreed, and when we will review if there are further delays.”
V – Verify prior results and imaging first
A – Ask: will this change management?
L – Least-burden equivalent test or treatment
U – Unite flow teams (pharmacy, therapy, site, transport)
E – Escalate and document constraints and review times
Define the clinical question and what result you need.
Check existing results and imaging before requesting anything new.
Choose the least burdensome safe option that answers the question.
Plan discharge and flow early; coordinate pharmacy, therapy, beds and transport.
Document constraints, safety-net and review times, and escalate when limits threaten safety or fairness.
📋 QUICK FAQ
Is the cheapest investigation always the right choice?
No. It must be clinically appropriate and safe. Choose the option that adequately answers the clinical question with minimal delay, risk and burden, while respecting patient preferences.
When is it acceptable to repeat imaging or tests?
When clinical status has changed, earlier results are no longer valid, or initial imaging was inadequate. Simply repeating a normal scan “to be thorough” without new information is poor stewardship.
How can juniors meaningfully improve flow?
Identify likely discharges early, start TTOs and therapy referrals in the morning, communicate intended discharge times with pharmacy and site team, and chase key tests in time for decisions.
What should I do if a resource limit is creating risk?
Explain the concern clearly (who is affected, how, and by when), escalate to senior clinicians and bed/ops managers, propose alternatives, and record the constraint and agreed plan in the notes.
Do resource constraints justify unsafe shortcuts?
No. If resources are insufficient for safe care, you must raise and document concerns rather than accept unsafe workarounds.
📚 GMC ANCHOR POINTS
* Using resources responsibly while providing safe care and avoiding waste (GMC Good medical practice 2024).
* Sharing information and decisions with patients using benefits, risks, reasonable alternatives and the option of no action (GMC Decision making and consent).
* Keeping clear, accurate and timely records, including rationale for tests and for managing delays or constraints (GMC Recording information).
* Raising and acting on concerns when system pressures or resource limitations may put patients at risk (GMC Raising and acting on concerns).
💡 MINI PRACTICE SCENARIO
A patient with typical biliary colic, abnormal LFTs and RUQ tenderness is clinically stable. CT slots are fully booked until tomorrow; ultrasound capacity exists this afternoon. Three other patients are medically fit for discharge but their TTOs have not yet been written; ED is boarding two patients needing ward beds.
Best action: Book an urgent RUQ ultrasound this afternoon as it safely answers the clinical question; start TTOs and therapy/transport planning for the three dischargeable patients with a clear target discharge time; inform pharmacy and site team of expected bed releases; document constraints and your escalation plan if imaging or discharges are delayed.
Why: This uses a least-burden equivalent test, improves patient flow, and makes constraints explicit, aligning with GMC guidance on resource use, consent and record-keeping.
🎯 KEY TAKEAWAYS
✓ Every investigation should have a clear clinical question and impact on management.
✓ Check prior results and imaging before repeating tests.
✓ Prefer the least burdensome safe option (for example, ultrasound before CT where appropriate).
✓ Plan discharges, TTOs and therapy early to keep beds flowing.
✓ Document constraints, safety-net and review points, and escalate early when limits are unsafe or unfair.
🔗 RELATED TOPICS
* → Prioritising Clinical Tasks
* → Resource Allocation & Fairness
* → Time & Resource Management
* → Working Under Time Pressure
* → Handover & Documentation
📖 FULL PRACTICE QUESTIONS
Example SJT — Best of 3 (8 options; choose three)
You are the medical SHO on a busy take. CT slots are full until tomorrow. A stable patient with RUQ pain, abnormal LFTs and typical biliary colic needs imaging. Pharmacy reports that TTOs for four likely discharges today have not yet been started. ED has two patients waiting for ward beds, and the site manager is asking when beds will be free.
Options:
A. Order an urgent CT abdomen and pelvis “to be thorough” and hope a slot appears, without checking ultrasound capacity.
B. Request an urgent RUQ ultrasound today, as it answers the clinical question; if the patient deteriorates, plan to escalate for CT.
C. Begin TTOs now for the four patients likely to be discharged, and inform pharmacy and site of target discharge times.
D. Delay all imaging until tomorrow to avoid overloading radiology and reassess then.
E. Repeat full bloods on all medical patients “for a clear baseline” before deciding who can be discharged.
F. Contact the site manager and explain that three beds could be released today if TTOs and transport are coordinated early.
G. Do nothing about flow now; focus solely on clerking new admissions and leave discharges for the evening.
H. Document the imaging and flow constraints in the notes and agree a review time if ultrasound or TTOs are delayed.
Correct three: B, C, F
• B: Uses the least burdensome safe investigation that answers the clinical question today and builds in a deterioration plan.
• C: Starts discharge work early, which improves bed flow and reduces system risk.
• F: Proactively coordinates with site management, linking clinical work to bed management and being transparent about resource needs.
Why others are weaker/wrong:
• A: Requests a higher-burden test without clear added value, ignoring equivalent ultrasound capacity.
• D: Delays appropriate imaging without justification, risking prolonged symptoms and delayed diagnosis.
• E: Orders low-yield blanket tests without linking to decisions.
• G: Ignores flow and discharge work until late, predictably worsening crowding.
• H: Documentation and review are good but not sufficient alone without the proactive actions in B, C and F.
Example SJT — Rank 5 (best → worst)
On a general medical ward, you are aware that beds are extremely limited. Several patients are clinically fit for discharge, but TTOs were started late yesterday and some stayed overnight purely awaiting medications. Today, pharmacy has asked for predictable TTO timings. Radiology has highlighted that CT capacity is very limited, and there is pressure from seniors to “be thorough” with imaging.
Options:
A. Identify potential discharges on the morning ward round, start TTOs and therapy referrals immediately, liaise with pharmacy and site with target discharge times, and only order imaging that will change management.
B. Continue to order CT scans for multiple patients with recent normal imaging “to be safe”, while leaving TTOs until the afternoon again.
C. Order a standard daily set of bloods and imaging for all patients so that “nothing is missed”, regardless of the clinical question.
D. Keep your concerns about delayed discharges and limited CT slots to yourself to avoid “causing trouble” with site and radiology.
E. Cancel all planned imaging and discharge as many patients as possible quickly, without considering individual clinical risks, to free beds.
Options:
A. Plan discharges and imaging based on clinical value, coordinating pharmacy, therapy and site.
B. Repeat CT “to be safe” and continue late TTOs.
C. Order daily blanket tests for all patients.
D. Stay silent about capacity risks.
E. Cancel imaging and discharge rapidly without regard to risk.
Ideal order: A (1) > B (2) > C (3) > D (4) > E (5)
• A: Best combines stewardship, safety and flow; clinically driven imaging, early TTOs and transparent coordination with pharmacy and site.
• B: Wasteful and poorly planned but at least not abandoning assessment entirely; still safer than indiscriminate discharge.
• C: Over-testing and poor stewardship but at least not cancelling necessary care; less dangerous than silence or reckless discharge.
• D: Fails duty to raise concerns; allows unsafe patterns to continue unchallenged.
• E: Most unsafe; frees beds by compromising individual clinical safety and informed decision making.
Define the clinical question
Order tests that change management
Check prior results; avoid repeats
Choose least-burden safe alternative
Coordinate discharges early with pharmacy/site
Document constraints and escalate when risky
Time-critical tests delayed with no escalation
Duplicate high-radiation imaging without benefit
TTOs started late, blocking beds
Capacity limits not recorded or escalated
- GMC — Good medical practice (2024)
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice - GMC — Decision making and consent
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent - GMC — Raising and acting on concerns about patient safety
https://www.gmc-uk.org/professional-standards/the-professional-standards/raising-and-acting-on-concerns - NHS England — Patient Safety Incident Response Framework (PSIRF)
https://www.england.nhs.uk/patient-safety/psirf - Academy of Medical Royal Colleges — Choosing Wisely UK
https://choosingwisely.co.uk - Department of Health and Social Care — Hospital discharge and community support: policy and operating model
https://www.gov.uk/government/publications/hospital-discharge-and-community-support-policy-and-operating-model