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

Appendix 6: Staff feedback from the NHS Lanarkshire pilot visit

General Points

Concerns were voiced from all groups and specialities being represented.

Main issues stemmed from lack of staff to physically cover all of the clinical areas required resulting in higher workloads across all, poor continuity of care and of training, with an overall detrimental impact on patient safety.

Would also impact on consultant working with an inevitable increase in outpatient clinic waiting times and elective theatre cases thereby directly affecting government targets. Concern was also expressed about the attractiveness of the Board (and Scotland) as a location to work if this were implemented, due to the poor work-life balance created by new shift patterns, workload and lack of support on shifts due to reduction in medical staff available at any point, and the lack of education that could be delivered within these constraints.

Some groups considered how many more doctors we might need to deliver this proposal without significant detriment. “30%” more? Definitely more than we have now” – a feeling we are already stretched for staffing with ever increasing demand.

There was also some feeling that looking at junior doctors as an isolated group wasn’t helpful as it didn’t promote team culture and may lead to resentment over their “special” protections if the proposal went ahead. There was also not a clear argument over why this rule shouldn’t apply to everyone if the evidence said it was a good idea [NB – see earlier papers/minutes of the 48h EWG for more on this – no clear evidence for 48 hours with no averaging]

Service Impact

• Insufficient juniors staffing across all levels to cover all clinical areas
  • 48h rotas – simply not enough FY1s on day time work to cover all the wards (have proportionally less FY1s than other units as they do not work nights)
  • At times one FY/SHO would need to cross-cover 2 wards (medical and surgical) – this is not safe or feasible
  • Insufficient staffing for receiving (medical and surgical)
  • Would need to alter consultant working in A&E to counteract the loss of trainee time in the department
  • Medical service ‘could not cope’ especially on Mondays and Fridays with the loss of daytime staff
• A sense with new rotas it would be “like induction week all the time” – (referring to August changeover when all staff are getting mandatory induction and other clinical staff find the shortage extremely challenging)
• Loss of continuity on wards; issues for wider team working and the benefits that go along with this (for all members of staff and patients)
• Inevitable effect on waiting list targets:
  • Surgical clinics would need to be capped at around 8-10 patients (i.e. manageable for one consultant only without a registrar) thereby taking away the flexibility that is there currently to add on other/emergency patients (currently run with 14-20).
  • Similarly many theatre lists need two surgeons (usually consultant and trainee), if a trainee could not be guaranteed this adversely affects waiting times, especially for more complex cases
• Felt it was extremely likely that consultant job plans would need to change to accommodate this reduction in trainees.
• Initially the new rota looked a lot better; however after discussion it was felt that continuity of care would be lost due to frequent changes in working pattern, discharges would take loner. Continuity of care was repeatedly mentioned.
• It was felt the half day suggestion would go down badly. It was felt that if you were in for a half day you would be inclined to work on as if you were already at work it was felt you would stay on.
• Trainees talked about fatigue and feeling worn out. Trainees felt a straight run of nightshifts were better as changing from day to night working could impact on sleep, health and childcare, it was less predictable that the current rota.
• Again, continuity of care was discussed with the new rota and handover and that things may be lost in translation and will impact patient care.
• Also, trainees mentioned ‘first night syndrome’ experienced when starting night shift and not quite switched; they feel most tired at the end of the first night, therefore this would happen regularly if there was not a straight run of nightshifts. 1 nightshift could wipe out 3/3 days.
• FY trainee didn’t anticipate any issues with the new rota, longer shifts would be split over a longer period of time.
• Trainees felt it would be really good not doing 5 days of receiving in a row.
• Again, the group discussed the half-day and felt this would not be helpful. Most training happens in the afternoon therefore half day finishing in the early PM would not be helpful for training purposes and trainees frequently stay on therefore trainees typically work a full day but are only getting paid a half day.
• A & E trainee again discussed ‘horrendous’ nightshifts and no scope to take A/L. It was felt the new rota’s the service would need to make provisions for medical cover
• A&E “Demand has vastly increased. I wouldn’t want to be the trainee on” [on these new rotas]
• HR – felt there would be less daytime cover and that training could be difficult. Split weekends for juniors would not work.
• Current rota once a month and time is protected.
• FY – new rota – lots zero days land Tuesday. FY teaching is a Tuesday, so this would need to be revised.
• Study Leave – currently pretty inflexible in A & E. New rota no standard days so could work.
• Different specialities have different needs and intensity.
• Need more training numbers
• Need for additional trainees or other medical staff to cover rota gaps
• Expected increased locum costs from new rotas, also less flexibility of internal cover as trainees couldn’t really do any additional shifts without breaching the new 48 hour rule [service manager group]

Staff and Patient Safety

• Huge concerns regarding patients safety given the loss of continuity as a result of the reduced working hours; this has an effect across all levels and specialities.
  • As mentioned above not enough foundation doctors to cover all wards
  • Few weeks where trainees would spend the entire week on the same ward
    • This lack of continuity on the same ward has been flagged a recent deanery visit in respect of the current medical foundation rota – the situation would be worsened by the new 48h rota.
• “Huge impact on safety and site flow performance” [service manager group]
  • “Prolonged stays while awaiting treatment would increase risk of patient harm”
• “It doesn’t feel like safe staffing at the moment” (and would be reduced further by this proposal) [service manager group]
• Doctor not working as many hours may be safer
  • But conversely reduction in availability would increase risk
  • Would lead to greater expectations on shift which might be negative – would increase in pace lead to more errors? Same number of patients still, just fewer doctors to look after them [service manager group]
• Knowing your patients results in better care; things are less likely to be missed and the care they receive is likely to be more efficient and streamlined
• Concerned this would result in much higher rates of burnout amongst trainees as, due to the reduction in staffing (especially during week time), the workload and burden whilst at work would be far greater
• Increase in number of handovers, higher change of critical information being missed
• Concern in increasing numbers of day-to-night shifts; known amongst the consultant body to be a time of higher risk
• Effect on other staff groups:
  • Consultants will have to take on more work to cover, concerns regarding consultant wellbeing. They have no such safeguards when it comes to hours worked per week
  • Concerned of the resilience of trainees; how would they cope as consultants should this be implemented? (i.e. protected during training, only working 48h then potentially huge increase in working hours on receipt of Certificate of Completion of Training)
  • Staff grade, associate specialist and specialty doctors would not be affected by this change, likely further increasing the marginalisation of this group.
• Medical SHO cover – real problem less than 3 people on. It’s already a stretch at present.
• Care of the Elderly would now only have 1 doctor covering 5 wards and ~120 patients. Also demand is increasing particularly in Hairmyres as this is an ageing population – likely to be overwhelming for this doctor vs. previous rota [service manager group]
• It was felt that with the new rotas people just wouldn’t leave and would end up working longer. People wouldn’t get discharged and this would impact adversely on health, fatigue and decision making.
• Current rota once a month and time is protected.
• FY – new rota – lots zero days land Tuesday. FY teaching is a Tuesday, so this would need to be revised.
• Study Leave – currently pretty inflexible in A & E. New rota no standard days so could work.
• Different specialities have different needs and intensity.
• Need more training numbers
• Minimum safe staffing for nursing can be calculated using computer tool (based on number of patients/beds) – can’t we do this for medical staff using e.g. Royal College guidelines? [service manager group]
  • Noted safe staffing bill currently progressing through parliament which might inform this
• Negative impact on waiting lists – feeling can’t really do any more already, with additional clinics/lists already added to meet targets

Employee Experience

• Concerns regarding inability to take adequate amounts of continuous annual leave
• • Would take annual leave on weeks of normal days thereby further reducing the number of staff working at these times.
• Noted more “days off” (due to required zero days) which might be positive
• • More “chopping and changing” felt to be “not good work-life balance”, with group noting “it’s been shown to be bad for your heart, for diabetes”
• Noted junior doctor annual/study leave “not accounted for” in the same way as nursing staff rosters do – often teams just need to do without staff when off – more vulnerable still if this proposal implemented with fewer staff [service manager group]
• Noted that many nursing teams seem to manage 48 hours without averaging – group asked to consider what lessons we might learn from this – noted breaches of 48h were allowed, but if consistent and overall excessive hours is escalated to a manager which triggers a discussion with staff member (e.g. those choosing to do overtime regularly) – e-rostering does help to identify this [service manager group]
• • Noted that nursing workforce larger and as several work on each shift on every ward, it is much easier to have flexibility to deliver this model
  • “If 12 hour shifts weren’t a thing there would be more flexibility” (but acknowledged would need more medical staff and fundamental service change in any dept. who did this to continue to cover service safely)
• Much less likely to work on same ward/with same team, reduced job satisfaction
• “Would worsen team structure, more shift changes and in less together”
• • Also this would “lose the importance of handing over as a team” – also potential patient safety risks in this
  • Group also noted that original EWTD being brought in (48 hours with averaging) had adversely impacted team working and continuity already, despite the hours reduction being positive
• Nurses and other team members much less likely to know ‘their’ juniors/trainees
• Higher workload whilst at work
• Increase in weekend working across many of the rotas, with some now containing split weekends (A&E junior) to facilitate 48hour working
• Half days which have been utilised on the 48hours to maximize hours at work would not work; feel most trainees would feel obliged to stay.
• New rota looks better but would depend what it looks like in practical terms.
• Medicine registrar – doesn’t look widely different but it could be a challenge to get speciality training. Would be increase in days not being at hospital and would get a lot of assessments done when on call.
• Trainees currently not getting to clinic.
• Surgical trainee losing days would have a major impact and would need to come in on days off just to meet the numbers required as part of surgical training.
• Discussed that may need extended, the group felt this could work for some and not for others. It was felt that if trainees are at work less they are effectively working LTFT and may as well just apply for LTFT. It was felt that if training time was extended if may put people off applying to Scotland. It was felt that it would be hard to find a way in the new rotas that would work for everyone.
• Trainees again discussed fatigue and intensity. It was agreed that they all probably work roughly the same hours but some specialities such as A & E are more intense
• Impact on team – not enough people on the rota, mores nurses may help, people regularly staff past their shift.
• Scans – ½ day – results come back in the afternoon – no one to discuss and come up with plan
• On call – for emergencies not routine so would need to wait until next day leading to a delay.
• Better for my wellbeing to split long day shifts but not good for continuity of care or for taking annual leave.
• No to half days
• This rota looks better for work-life balance. –Medical junior tier
• I like the idea of splitting up the long shifts. – FY1 medical
• Keep blocks of long days together so I can plan my life better. Get them all out of the way at once. Helps with child care and taking leave.
• Half days are a terrible idea.
• Please don’t give me 1 night shift. I find the first night shift the hardest. I’m always exhausted at the end of the first shift – ‘first night fatigue’ but then I get into the pattern by the second night. Not good for my health or the patients.
• Too much switching between days and nights.
• Spreading out long shifts may reduce burn out.
• No opportunity on ED senior rota to take any leave at all on this rota.
• Don’t like multiple handovers, I like to know my own patients. Increase time, increased mistakes, and increased errors.
• “Evening very demanding time. Reduced senior cover will be negative. Poor for morale” [service manager group]
• Impact on nursing staff++ in workload and what they might need to manage with less medical availability [service manager group]
• • Potential to develop more extended roles for Nursing/AHPs – this might be attractive and present more advancement opportunities which nurses are keen for (additional cost though) as well as better continuity of care in the longer term as these would be permanent roles rather than juniors who rotate frequently
    • Noted that originally developing and rapid expansion of these roles left somewhat of a chasm – few experienced staff nurses were left on wards, with experienced nursing becoming ANPs/Ward Managers etc. and most staff nurses being the newly/recently qualified – perception this was not positive for day-to-day ward based patient care – risk would need mitigated
    • Group considered are we even training enough nurses to allow for this or would it just lead to more gaps on the wards?
  • Felt nurses would have to escalate more work to Consultants if juniors not available, or delays due to less doctors resulted in patients becoming more unwell and then needing seen by a senior. Felt that Consultants already do not have the capacity for this
  • Acknowledgement some work could still “be done better” and that “learning by default” could be the usual rather than a good educational structure – this could potentially improve efficiency

Educational Quality Impact

• Overall felt that resulting increased demand on doctors from the changing rotas will adversely affect education
  • Around 3-4 fewer doctors per day in most departments/rotas leads to more pressure on the remaining ones
  • Acknowledged still would need to hit national targets e.g. 4 hour wait, 12 week treatment target etc.
  • Consultants having to pick up more work due to reduced junior staffing would further reduce their ability to teach as well as junior’s ability to attend
• Again major concerns voiced across all specialities regarding all levels of training
• Surgery
  • Currently work in team based 1:1 system (consultant: higher trainee) with cross cover for training
    • Reduction in training time, frequent repetition needed more so in craft based specialties
    • Huge reduction in the ability to attend the same theatre lists/clinics with massive impact on training progression and ability to meet curriculum requirements
    • Reduction in ‘trustability’; specifically the relationship developed between consultant and trainee over a prolonged period of time.
    • Reduced continuity of care (especially post op) patient safety issue
      • Higher rates of ‘failure to rescue’
    • Insufficient time for attendance at teaching for junior trainees
    • Loss of ‘informal’ teaching of junior trainees from those more senior
    • Would be unable to meet the requirements for core or higher surgical training
    • Should this rota be put in place it would have to be flagged to the colleges and likely trainees would be removed
      • Would not meet minimal requirements for core or higher surgical training.
• Medicine
  • Concerns as mentioned above regarding lack of continuity on current rotas
  • ‘Taster nights’ for FY1s hugely popular; would struggle to facilitate the study leave to allow this to happen
    • Also need sufficient senior staff to supervise them at on these shifts
  • Would be almost impossible to get IMT and higher medical trainees sufficient clinic time based on the parameters set in their curriculums (this is an issue on the current rotas)
    • IMT ST1 = 20clinics
    • IMT ST2 = 40clinics
    • IMT ST3 = 20clinics
  • Senior trainees would struggle to meet requirements of their individual higher medical curriculums
  • Would fail to make teaching attendance across all levels
    • Teaching could not be repeated as insufficient consultant time
  • Reduced supervision across all levels in view of reduced senior staffing at higher tiers
  • Impact on ability to take study leave
• Emergency Medicine
  • Senior rota would be unworkable
  • Would be unable to provide adequate educational opportunities in view of the increased number of zero days
  • Increase in weekend working – not best for training.
  • Reduced senior staffing to supervise juniors.
• Overall feeling of the loss of training time would be hugely detrimental to all trainees
  • Potential for higher rates of poor ARCP outcomes as training needs would not be met leading to extension of training and potentially issues gaining further training/time out of programme/ consultant jobs
  • Scotland wide ‘extensions’ to training would also not be attractive as this would take us out of sync with the other UK nations
• Current rota once a month and time is protected.
• FY – new rota – lots zero days land Tuesday. FY teaching is a Tuesday, so this would need to be revised.
• Study Leave – currently pretty inflexible in A & E. New rota no standard days so could work.
• Different specialities have different needs and intensity.
• Need more training numbers
• Losing more than 50% of my standard days will be devastating on my training. I will not be able to complete the curriculum: not enough time in theatre, not enough cases in log book, not enough continuity with my clinical supervisor/trainer, not enough opportunity to do WBA.
• Would loss the ‘team culture’ by doing loads of nights and zero days.
• “Less clinic time and less time on ward with others. If we dilute training too much, juniors would not be seen as part of the workforce by other staff”. –[Potentially harmful to training, wellbeing and workplace culture] [service manager group]
  • Risk consultants escalated to more often and “juniors will be left doing admin rubbish” [not valuable for training)
• Would not be able to go to clinic and therefore not be able to pass my ARCP.
• “If this was done across Scotland, how would anyone be able to meet their training requirements?” [service manager group]
• Lots of zero days will impact of training
• FY1- we would like to do nightshifts (with appropriate supervision) as these are a fantastic learning opportunity and it would ease the transition to FY2.
• 48hr average week would be disastrous to craft specialities training.
• Can still do SLE on call but would loss daytime training opportunities.
• Reduced time with own supervisor.
• Increased intensity of work equally bad for burnout!
• Study leave would be difficult to take due to inflexibility of the rota with swaps.
• Feeling that rotas would lead to more need for/use of locums and that overall this creates less of a training ethos and overall would be detrimental to educational quality in depts

Alex Rice and Chris Sheridan