Junior doctors - 48-hour maximum working week (without averaging): expert working group report

Appendix 5. Request for Educational Approval of Draft Hairmyres University Hospital Rotas – 48 hour maximum working week (without averaging) (Professor Clare McKenzie in consultation with other Postgraduate Deans)

We recognise that these are theoretical rotas and would highlight that in most departments, currently, a full complement of doctors in training is not the norm. Therefore, in practice, the concerns around attaining curriculum competences/capabilities are likely to be compounded when gaps in rotas and unanticipated leave are taken in to account.

Educational approval is primarily based on the ability for doctors in training to be able to access training opportunities described in their respective curricula which includes both on the job training and formal teaching. Added to that is the need for supervision appropriate to the trainee level. For doctors in training to learn appropriately, rota structure (shift lengths and breaks) as well as the frequency of unsocial work should be considered (which impacts on work-life balance, family and relationships). Both of these are important and can influence the attractiveness of posts.

Lastly, the proposed rotas seem to offer less frequent team working and less frequent continuity of care which both are known to adversely impact patient safety and care. Service leads would need to consider how to mitigate this with other members of the multiprofessional team and what would be the workforce consequence.

It has been challenging to consider these rotas in isolation of knowledge of service delivery and local organisation of training. In relation to specific rotas submitted for this exercise:

Medicine rotas

1. Foundation 1 rota. The foundation curriculum is generic and competences/capabilities are achieved throughout a training year in multiple different posts which means that, generally, it is easier for foundation doctors in training to achieve the curriculum requirements because of the varying environments that they will work in.

Summary - This rota could be approved (as there is a consistent shift time and largely daytime activity), provided that formal teaching can be accessed and that there is sufficient supervision. The former requires to be clarified and timetabled into the rota and service requirements. The latter would need to be guaranteed for foundation doctors in training and patient safety and it is not entirely clear whether this will be possible from review of the higher medical rota. Greater amounts of supervision may be necessary by consultants.

2. FY2/GPST/Junior StR rota. The above comments regarding foundation apply for the foundation doctors in this rota. There are concerns that this is a rota involving doctors with different levels of competence. Ensuring clarity of these doctors’ competences by all members of staff will be essential for patient safety. Supervision arrangements will need clarification before this rota could be approved. For the GP STs there is insufficient information to ensure that allows them to meet curricular requirement around attendance at outpatient clinics. For the Junior StRs, again insufficient information and assurance that they will be able to attend the clinics or intensive care requirements of the IMT curricula.

Summary – rota will need modifications to ensure that the doctors in training within the different programmes can achieve their competencies/capabilities. F2 supervision requires to be described, GP ST access to clinics and GP teaching programme, Junior StRs are able to attend sufficient clinics to meet curricular requirement (particularly important for new IMT programme)

3. Senior Medical StR Rota. The reduction in daytime training activity is noted and would be expected to reduce the opportunity to attend clinics. This is likely to be especially problematic for those in higher medical training, although not restricted to this group, who need to gain the procedural competences required of the curricula. There are already challenges to achieving these requirements in some higher medical specialty training programmes. This could potentially affect training progression.

We note the frequency of weekend working which could make the posts unattractive.

Summary – this rota cannot be approved for those in higher medical training as there is insufficient access to both general and specialist clinics. If more clinics were to be timetabled outside of the standard working week and which could align to trainee working, educational approval might be possible.

Emergency Medicine rotas

1. Foundation and GPST Rota looks less than optimal with variable start and finish shift times. It is unclear how safe handover would be arranged and whether doctors in training would have access to the formal teaching programme. There is concern about the shift pattern leading to potentially tired doctors and poor sleep patterns which do not promote wellness.

Summary - this rota would not gain educational approval and a remodelled rota would be requested which shows more pattern to shift patterns, describes handover and incorporates formal teaching.

2. For senior EM StRs there is a lot of out of normal working hours activity with concern about the amount of supervision and training that will be provided. The detail of the consultant rota is important to understanding how doctors in training will gain their competencies/capabilities. Information about how formal teaching will be provided with this rota is needed. The shift seems to finish at 2 am which seems unreasonable and potentially negative for recruitment and retention.

Summary more information is required to comment upon this rota.

Surgery rotas

1. Foundation rota – the comments for this rota are the same as for that foundation medical rota.

Summary – potential for rota to be approved with need for clarity on protection for formal teaching timetabled into the daytime rota and for clarity as to who is supervising doctors in training at all shifts.

2. Foundation/GPST rota – the comments for this rota are similar to that for foundation/GP medical rota. There is a need to describe how the different doctors in training will achieve their respective curricular competencies/capabilities. GPSTs require to be able to attend clinics and attend their formal teaching.

Summary – rota will need modifications to ensure that the doctors in training within the different programmes can achieve their competencies/capabilities. F2 supervision requires to be described and GP ST access to clinics and GP teaching programme.

3. Senior StR rota. There is concern that core higher doctors in training will lose opportunities to attend supervised daytime sessions especially theatre sessions which are needed to gain the curricular competences. This could compromise the objectives in the Improving Surgical Training (for core training) initiative. It is noted that clinics and operating lists do not occur on everyday time session hence doctors in training may be present but these training opportunities are not available. This is likely to affect progression through training. Additionally, there are some concerns about the short turnaround of the long day to the next day (11.5 hours) as it is not always possible to leave on time. This, added to any commuting time, may result in very little real rest time. For educational approval, further explanation would be required which addresses how education/training will be provided out of hours by the consultants or whether alternative training options will be provided (regular simulation could help but would not be a replacement).

Summary: the rota cannot be approved for the above reasons. Potential options to address the reduced access to the training opportunities could be explored which might involve increasing the number of theatre/clinic sessions to cover all week day sessions, adding regular quality assured simulation, extended day operating sessions.