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

Appendix 7: Rota exercise at Hairmyres Hospital

Background

• The present contract is not particularly popular
• Main issue is 12-hour shifts: fatigue and recognised underperformance near end, no consultant presence, delays in handover mean work longer hours than rostered
• Varies according to individual specialities and stages of training
• No single rota will ever be acceptable to all
• Appreciate being involved in rota design and that HR at Hairmyres very helpful in providing solutions to issues when planning study time, annual leave and emergency absence

Service impact

• Proposed rota for 48 hr max working week, without averaging, looks attractive and could be better than the existing rotas
• Continuity of patient care may decrease by reducing weekly contact with patients
• A&E going to 4 on a 12 hour shift not sustainable for the workload and is a patient safety issue
• Similarly having only 3 on duty for Friday evening in A&E is not feasible – very busy
• Rota gaps will remain a problem – fatigue and stress for solo-working juniors
• Additional work for HR department, and may need to employ more locums. Better to spend the funds on training more doctors/specialist nurses, but that requires long-term planning and a more strategic approach

Staff and Patient safety

• Continuity of care will be compromised by reducing trainee and Consultant daytime cover
• The reduction in working hours will inevitably affect the patient experience, in terms of waiting longer to be treated (assuming demand from the ageing population continues to increase)
• Changing working hours for junior doctors could adversely affect other NHS workers – consultants, nurses, allied health professional and support staff
• Team working is crucial in healthcare, and the consequences of making changes for one group need to be carefully considered in order to retain goodwill and collaboration in teams
• Fatigue being experienced by junior doctors is a recognised risk to patient safety, and to the trainees’ personal safety and well-being. This may improve with the proposed rota
• Electronic patient records with automatic updating of e.g. lab results and ready accessibility would enhance the ability to deliver safe care to patients and reduce inefficiency
• Provision of quiet restroom and taking a nap during night shift, taxi home when fatigued and realise that driving home, sometimes long distances, could be a danger to public and themselves. The evidence of increased risk is appreciated, but it is not realistic at present to take precautions - because of workload and admin aspects for arranging the support.
• Fatigue isn’t just about the hours worked, it is also the workload, the support available, and the ability to take a break during e.g. a 12 hour shift. A short shift running with a gap in the rota can be very stressful for the individual junior trainee.

Employee experience

• 12-hour shifts in busy units lead to “decision fatigue” - max should be 10 hours, as last 2 hours of a 12-hr shift are generally when tiredness becomes a patient and personal risk
• Unable to take break(s) during 12-hour shifts, or shorter shifts, and at weekends because of lack of workload and lack of cover for break times. Know should take a break, but workload makes it impossible without compromising patient care.
• Stress associated with juniors taking decisions is heightened by lack of Consultant presence at night and weekends, particularly relevant for handover for deciding on the patient’s care plan at a time when workload means junior doctors are commonly fatigued. Varies according to the Unit.
• Junior doctors are commonly less likely to seek advice from on-call Consultant than more senior SR trainee doctors. Use modern IT to dialogue with on-call SR/Consultant, or require the senior colleague to call in, e.g. before end of shift.
• Having electronic notes available would increase efficiency and reduce stress for junior doctors, and could reduce risk for patients. Still need face-face with staff during handover
• Like not doing Friday receiving
• Split weekends as an option
• Half day rostering is not a viable option. Personal experience is that you end up working on until 3pm.
• If required to come in for only a morning, would inevitably stay longer – psychology
• A single night is not acceptable in the rota. Prefer a series of 4 nights, and it is the first night that is most disruptive as adjust to change in sleep pattern
• Avoid rostering nights following back shifts
• Good for F1 to have a taster experience of working nights (Mon-Thurs) but needs more senior trainees available to supervise them
• Study leave looks good, as is the case at present
• Flexibility and collaboration with Consultant (ES, CS) and HR is a key factor in achieving optimal work practice and personal well-being

Education Quality Impact

• Reducing trainee and consultant daytime cover will affect training of juniors and continuity of care
• Prefer to have training experience with one designated Consultant, rather than a random allocation of trainee and Consultant (CS) to meet a 48-hour max rota without averaging
• Could work if increase the number of junior doctors, Consultants, specialist nurses, phlebotomists available at crucial times in what is a 24/7 operation being run at present on a five day working week
• Non-clinical days are good in the rota, as are zero days
• Need to protect training days – looks OK on the proposed rota, similar to existing
• Does 4 hours per week education time fit the revised rota?
• Need to ensure that teaching doesn’t affect zero hour days on a regular basis
• Extending training time to achieve the 48-hour (without averaging) target would suit some, but overall this would not be desirable. Would put Scotland out of sync with England/Wales/NI, and could adversely affect recruitment. Would the Colleges/Deaneries allow national differences, given they are responsible for postgrad education and training on a GB-wide basis. In any event many trainees already take time out or work less than full time - prolonging time to receive Certificate of Completion of training is not attractive for most trainees
• Some aspects of local and regional training days could be enhanced by using IT to access course/material remotely – i.e. distance learning on-line. Most trainees prefer to attend in person so as to ask questions and network with fellow trainees, but IT would be useful when rota clashes make it impossible to attend. There are problems in accessing resources on-line within hospitals, so this should be solved to enhance education and training in a shorter working week

Final discussion of key points (all groups together)

• Overall, willingness to consider changing rotas, and appreciation of being consulted
• Consultants would be unable to deliver F1 teaching on this rota – impossible to run it, and would no longer be able to train junior doctors
• Question of how the “New Deal” and minimum staffing levels, currently with Scottish Government, will impact on the 48-hour without averaging working week for junior doctors?
• The rota would reduce team working, and affect the work of nurses and Consultants
• Takes time to recruit and train specialist nurse practitioners and doctors (medical student through to Consultant)
• Nurses are on a 37.5 hour working week, and that may compromise teamworking with junior doctors who are working the revised rota
• Generally accepted that shifts should not exceed 10 hours in terms of safety of patients and staff. Flexibility is needed for e.g. surgery, A&E, but goodwill of staff should not be compromised by inadequate staffing levels
• Generally agreed that main problem in the NHS is the need for more staff
• Ultimately improving patient healthcare and well-being of NHS staff is a political matter relating to resources (funding), rather than one for HR/doctors/nurses/AHPs

Daniel McQueen