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

3. EWG programme of work

3.1 Design 48 Hour working week rotas with no averaging

Summary of current Junior Doctor rotas in Scotland:

There are over 800 different Junior Doctor rotas in operation across NHS Scotland, covering all grades and specialties, and in settings ranging from large urban teaching/trauma centres to rural and community healthcare.

The current approval process involves:

• Design and endorsement by territorial board Human Resources departments as meeting all applicable employment safeguards, with input from service and medical staff
• Approval for use by Junior Doctor representatives
• Educational approval by NHS Education for Scotland (NES) through the accountable Postgraduate Dean for each programme. (Detailed in section 3.2)
• Approval from the Programme Director of the New Deal Monitoring team, situated within the Scottish Government Health Workforce, Leadership & Service Reform Directorate.

Currently template rotas are prepared in Health Boards on the Doctors Rostering System (DRS), which is a computer-based system that calculates hours worked and ensure rotas meet safeguards set out within legal and contractual rules. The system also ensures compliance with the Working Time Regulations which stipulate a 48-hour maximum working week, averaged over a 26-week period.

Pilot rotas for 48 hour maximum working week:

NHS Lanarkshire agreed for University Hospital Hairmyres to be the pilot site for 48 hour maximum (without averaging) rota design and for the subsequent site visit. While no single site could be representative, nor the results predictive of every specialty rota across Scotland, Hairmyres was an ideal test site, combining busy 24/7 acute care service provision across different specialties with a significant training and education commitment. The pre-existing rotas met all local and national educational requirements, and were compliant with the Working Time Regulations, the 2002 New Deal Contract for Junior Doctors, and the Scottish Government Directive (Ending of 7 nights, Max 7 shifts in a row, & minimum 46 hours rest following nightshifts).

Pilot 48 hour maximum working week (without averaging) rotas were developed based on current staffing from February 2019 for 6 months to reflect as accurate a picture as possible. Rotas were selected for 3 specialties to give a broad spread and across all training levels in order fully to assess the impact.

Those included are:

• General Medicine Foundation Year 1 (FY1)
• General Medicine Junior (Foundation Year 2 (FY2), General Practice Specialty Trainees (GPST), Core Medical Trainees (CMT1-2)
• General Medicine Senior: Medical Specialty Trainees (ST3-7)
• General Surgery Foundation Year 1
• General Surgery Junior (FY2, GPST, CT1-2)
• General Surgery Senior (ST3-8)
• Emergency Medicine Junior (FY2, GPST, Acute Care Common Stem Trainees (ACCS))
• Emergency Medicine Senior (ST4-6)

Please see Appendices 2 and 3 for the current and proposed pilot rotas.

The 48 hour maximum working week (without averaging) rotas were produced using the Doctors Rostering System (DRS) as above. Some presumptions were made in the formulation of these rotas, these include:

• No change to staffing numbers
• All on call commitments should remain the same across both rotas (i.e. out of hours work – likely required to continue to provide a safe service)
• No change to other staffing within the departments ( of other doctors, nurses or allied health care professionals)
• Where possible no change to the shift timings (to continue to facilitate handover)
• Loss of normal working days equate to loss of training time

The new rotas also meet all other current working hours requirements as referenced above.

Rotas were produced by Scottish Clinical Leadership Fellows working within the Scottish Government Health Workforce department. In order to allow more in-depth assessment of the impact of the proposed change, the group agreed to focus analysis within one site so as to allow more accuracy in modelling. Rotas were produced to maximise the protection of service delivery and training time by retaining as much working time as possible within the confines of all mandatory hours limits and 48 hour (without averaging) limit. The analysis should be regarded as a “best case” scenario. Were, for example, staffing to reduce (which is common with natural fluctuations), or a department have specific additional clinical needs when rostering staff, the resulting changes required is likely to reduce overall hours, training time and possible daytime service cover further, which could have a direct impact on front line patient care.

There are important educational implications of rostering Junior Doctors to work in ‘normal working hours’ (weekdays 8am to 6pm) and ‘out of hours’ (weekends, and from 6pm through to 8am). During ‘normal working hours’ the full range of hospital support services are operational and most planned, elective clinical care and essential clinical and managerial meetings take place. In addition, most of the formal educational activities take place during normal working hours. All these activities and experiences are essential to fulfil the bulk of the GMC approved curricular requirements that enable Junior Doctors to progress and successfully complete their training programmes within the ‘indicative training time’ approved by the GMC for each specialty. Out of hours experience is also an essential component of training for specified areas of emergency care in each specialty curriculum.

However, many essential curriculum educational outcomes cannot be delivered out of hours, even if there were to be increased consultant time and educational supervision, because elective and planned care does not take place then. The balance of rostered time in ‘normal working time’ (predominately) and ‘out of hours’ is therefore essential to deliver specialty curricula within the required indicative training time.

The 48 hour maximum (without averaging) rotas developed for Hairmyres University Hospital with the underpinning analyses and comparisons with pre-exiting rotas are detailed in appendices 2 and 3.

Limitations of Analysis:

1. Rotas were redrafted extensively as part of this exercise and have been maximised to the limit of what is possible to protect training days and maintain working hours within current contractual safety limits and employment laws – despite this, all rotas experienced a significant reduction in total hours and training time, as well as a deterioration in work-life balance and employee experience measures

2. As per guidance from the 48 hour EWG, the tabletop exercise has devised rotas which do not exceed 48 hours in any Monday – Sunday 7 day period

• Therefore it is possible that >48 hours could be worked if considering any consecutive 7 day period, e.g. Week 1: Friday, Saturday & Sunday shifts 0800-2100, Week 2: Mon-Thursday shifts 0900-2100 would total 87 hours in a 7 day period (but each Monday-Sunday 7 day period would not exceed 48 hours)
• Early modelling based on a 48-hour maximum in any 7-day period strongly suggests it would be even more difficult to achieve without further adversely impacting on training time, ability to take leave, changes from days to night, weekends worked and all other proxy measures analysed. In all rotas assessed under this parameter, trainees would work on average <40 hours a week which would result in them being classed as in less than full time training with the consequence that training would not be completed within the approved indicative training times (see option 3, page 30)

3. Producing rotas that achieve the 48-hour maximum working week (without averaging) objective and all existing requirements around contractual safeguards and training has been very labour intensive. It would represent a significant workload to roll this out across the 800+ rotas currently in operation in Scotland. It is also likely to be more challenging within larger services and other specialities working on more complex sites than those analysed to date

4. The scope of the analysis undertaken only covers the impact on Junior Doctors, and does not include Staff and Associate Specialist Doctors or other professionals such as Advanced Nurse Practitioners and Physician Associates who also work within services and on the same rotas at times, who would have their own requirements and contractual rules to take account of, and could be affected by any change to junior doctor rostering as an unintended consequence

Conclusions:

From this exercise, there are a number of generic conclusions that can be applied to 48 hour maximum (without averaging) working week rotas utilising existing service and education models and current Junior Doctor staffing establishments. These are likely to be applicable to all specialties providing 24/7 acute care services across the spectrum of geographies in Scotland:

• Moving from current rotas to 48 hour maximum (without averaging) rotas can only be achieved with an increase in the percentage of Junior Doctor working time spent out of normal working hours
• One unintended consequence of this will be greater fragmentation of Junior Doctors’ working time, with potentially detrimental impacts on their experience of daytime, team-based routine and elective care
• The reduction in normal daytime working will result in a loss of training time for Junior Doctors (see Appendices 2 and 3 for predicted losses in individual rotas). This may be partly compensated for by increasing the formal educational opportunities delivered ‘out of hours’, but this will require additional consultant time and extended on-site presence, with protected educational supervisor time. Furthermore, there will be many essential requirements of specialty curricula (e.g. elective surgery, planned ward rounds, multi-disciplinary meetings and out-patient clinics) which can only be delivered during normal working hours
• There will be adverse service impacts of reduced Junior Doctor availability during normal working hours, with the likelihood of reduced service activity unless additional staff can be recruited
• There is a significant risk in some specialties that the GMC required curricular outcomes will not be delivered within the approved indicative training time for each specialty due to the loss of normal working time. This would result in a complex issue of having to extend indicative training time to Certificate of Completion of Training either for individual Junior Doctors or systemically for all trainees in specific specialties (see analysis in Appendix 2 and discussion in section 6.2)

Alex Rice and Chris Sheridan

3.2 Educational Implications of proposed 48 hour rotas

In considering rota changes, in addition to taking account of compliance with legal requirements and service delivery, it is also essential that the rota ensures that the doctor in training has the opportunity to achieve the educational outcomes of their training programmes. Scottish Government HDLs identify that there is need for an educational approval process, however, are not prescriptive about how this is achieved. Within NHS Scotland, NES, as the GMC approved Deanery, approves rotas from an educational perspective. Assessment of educational approval for the EWG was led by the representatives from NES.

Current Processes

To date, there has been no standardised way that rotas are checked across NHS Scotland nor was there consistency in how approval was sought from the Deanery. Each of the four Postgraduate Deans approached the request for educational approval in a different way although there was commonality in the need for detailed educational information. Information gathering will vary according the curricular requirements, detail of the provision of formal teaching on site and other factors specific to the specialty location and service. It is important to recognise that educational approval is for doctors in formal training programmes and that many rotas contain non-training grade doctors for which the Deanery has no role in approving their rota contribution.

Proposed Processes

Participation in the desktop exercise as part of the Expert Working Group has identified the benefit to trainees, service leads and educational leads of a clearly articulated process for educational approval of rotas.

Building on previous work within the North region of the Scotland Deanery, a Rota Checklist and flow chart has been developed by Scotland Deanery in consultation with Scottish BMA JDC (Appendix 4). This clearly sets out the need to provide evidence that the curriculum can be achieved, that formal teaching is built into the rota as well as promoting patient and trainee safety by ensuring necessary handover time and shift patterns as set out by Scottish Government. The Rota Checklist will also promote compliance with the GMC standards as described in ‘Promoting Excellence: Standards for medical education and training’ (GMC, 2015).

By defining the requirements, the Rota checklist ensures that all the necessary information is provided, in addition to the computerised trainee rota. This will allow the Scotland Deanery to make an informed educational approval decision.

To ensure that there has been thorough consultation, there is a requirement for trainee representation involvement, educational lead and service lead approval as well as the rota administrator.

The checklist will also support the implementation of recommendations for safer and more robust rotas which reflect the reality of staffing rather than a notional full rota in Caring for Doctors, Caring for Patients (GMC 2019).

The Scotland Deanery will retain the submitted information and approval (or not) decision. This will allow access by deanery teams, DMEs or trainees who request the information. This resource could be valuable to quality management of training programmes allowing a process of checking the working rota against the approved rota at the time of deanery quality management visits.

It is important to ensure consistency of process and fairness for trainees across the different training environments. This Rota Checklist will be implemented by the Scotland Deanery for all rota changes from Jan 2020. The deanery will review the process and the quality of information submitted one year after implementation to consider whether modifications are required.

Educational Approval of 48 hour maximum working week (without averaging) pilot rotas for Hairmyres University Hospital

As part of the desktop exercise, the Postgraduate Deans within NES reviewed the template 48hour rotas for the EWG.

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. Consideration is also given to the other aspects of rota design in considering appropriate learning. For doctors in training, 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.

In their current iteration, none of the 48 hour maximum (without averaging) working week rotas developed for Hairmyres University Hospital would be given educational approval (Appendix 5).The proposed rotas seem to offer less frequent team working and less frequent continuity of care than current rotas. These are both are known to adversely impact patient safety and care.

Clare McKenzie and Anne Dickson

3.3. Site visit to Hairmyres University Hospital to explore the impact of proposed 48 hour rotas

Having modelled potential 48 hour maximum (without averaging) rotas for different specialties at Hairmyres University Hospital, the EWG conducted a visit to the site to meet with different staff groups. The purpose of the visit was to obtain qualitative data and staff feedback on the global impact of introducing these rotas.

The visit team was led by the EWG Public Partner (Daniel McQueen) and included Scottish Government/NES Clinical Leadership fellows (all junior doctors with in depth understanding of rota design software) and volunteer quality assurance managers from NES.

NHS Lanarkshire staff were recruited by local management and consisted of four different groups: Junior Doctors; Medical Consultants; Nursing and Allied Healthcare Professions staff and medical managers. All participating staff were sent the pilot 48 hour maximum working week (without averaging) rotas in advance of the visit.

Daniel McQueen (on behalf of the EWG) and Dr John Keaney, Medical Director, Acute Division, NHS Lanarkshire hosted the event.

Qualitative data and feedback was obtained through 4 separate focus groups. Each group was facilitated by an EWG member/clinical leadership fellow and a NES QA manager to encourage open discussion and feedback within each staff group who would be affected were these 48 hour maximum rotas to be introduced. The discussion was structured to ask each staff group in confidence about the potential impact of the rotas on: Service Impact; Staff and Patient Safety; Employee Experience and Educational quality.

Feedback from the four focus groups is detailed in appendices 6 and 7. There was strong concordance from all the focus groups in spite of the different staff groups represented. There are some consistent, high level conclusions that can be drawn from the exercise:

1. Service impact

a. Reduced availability of Junior Doctors during ‘normal working hours’ would have a negative impact on service provision and waiting time targets. (Loss of 3 or 4 Junior Doctors during ‘normal daytime working’ in most departments)

b. Out-patient clinic numbers may have to be restricted as Junior Doctor presence cannot be guaranteed

c. Concerns about the continuity of patient care because of increased fragmentation of Junior Doctors’ working week and increased cross-cover

d. Loss of consultant time due to daytime cover for Junior Doctors

e. Potential increase in locum costs

2. Staff and patient safety

a. Patient safety concerns because of frequent handovers, fragmented working pattern for Junior Doctors and cross-cover of multiple wards ‘out of hours’

b. Increased number of ‘day to night’ shifts necessary to achieve the 48 hours associated with increased risks of both fatigue and medical errors

c. Further erosion of multi-disciplinary team culture on wards (due to loss of ‘normal working hours’ time for Junior Doctors)

3. Employee experience

a. Potential impact on attractiveness for recruitment purpose

b. Adverse impact on work/life balance for Junior Doctors because of inflexibility of new rotas

c. Increased number of weekends and split weekends at work will adversely affect work/life balance for Junior Doctors

d. Difficulty in arranging study leave and annual leave for Junior Doctors because of inflexibility of rotas

e. Potential benefits to Junior Doctors of splitting long days into half days (although adds to problems of continuity of care for patients)

f. Impact on consultant job plans

4. Educational Quality

a. Significant loss of education in every rota

b. Increased numbers of zero days would result in loss of formal educational activities (although the days off work were perceived as a benefit by some Junior Doctors)

c. Risk that specialty curricula cannot be delivered within GMC approved indicative training time because of loss of ‘normal daytime working’

Alex Rice, Chris Sheridan and Daniel McQueen

3.4. Evidence on Fatigue and relationship to hours of work and rota design

Whilst the EWG programme of work was focussed on the changes required to implement a 48 hour maximum working week (without averaging) for Junior Doctors, there was agreement that recommendations for change could not be effective or safe without considering the impact proposed changes may have on fatigue.

In the absence of robust evidence of the impact of the rota changes necessary to achieve a 48 hour maximum working week (without averaging) Lewis Hughes and Luke Yates undertook a literature search and critical review of the available evidence on behalf of the EWG:

Fatigue: What it is and why Junior Doctors are at greater risk

Definitions of fatigue vary in the literature, and the terms tiredness and drowsiness are used interchangeably in a number of publications^[1]. We offer two widely accepted definitions:

“A state of feeling tired, weary, or sleepy that results from prolonged mental and physical work, extended periods of anxiety, exposure to harsh environment, or loss of sleep.”^[1]

“Fatigue is the decline in mental and/or physical performance that results from prolonged exertion, lack of quality sleep or disruption of the internal body clock. The degree to which a worker is prone to fatigue is also related to workload. For example, work that requires constant attention, is machine paced, complex or monotonous will increase the risk of fatigue.”^[2]

Doctors (and other clinical staff) are at an increased risk of fatigue because they routinely, and increasingly, work long hours and variable shift patterns, and are exposed to excessive and high-intensity workloads. In the GMC National Training Survey 2019 (response rate 95% of all UK Doctors in Training) about one in four reported feeling ‘burnt out’ by their work with 56% reporting that they always or often feel ‘worn out’ at the end of the day. 45% of trainees report working beyond their rostered hours on a daily or weekly basis; 39% rated their workload as heavy or very heavy^[3]. Fatigue and shift working are recognised risk factors for wellbeing and clinical errors. Employers have a legal duty to consider the risks to safety presented by shift work^[4].

How fatigue and its contributors impact on Doctor-Patient safety

Fatigue and Working Hours

Longer working hours are associated with greater risk of fatigue^[5]. We are not aware of any evidence that directly addresses the relative risks to a doctor’s safety working above or below a threshold of 48 hours in a given seven-day (168-hour) period. Acute fatigue (resulting from extended time on a single shift or time awake without rest) impairs attention, performance and working memory capacity^[6]. While it is difficult to accurately determine how the level of risk changes over the period of time worked, there is some consensus from studies of shift workers that longer shifts (defined as shifts at least 10 or 12 hours long in the literature)^[7] are associated with a 25-30% higher risk of accidents and injuries than an eight-hour shift^[8–10]. Research specifically in physicians demonstrates an increased risk of road traffic accidents after extended shifts over 24 hours^[11], and a higher risk of needlestick injury during extended shifts over 20 hours^[12]. An individual who experiences moderate sleep deprivation (equivalent to being awake for 17-19 hours) can have the same reaction time as being at a blood alcohol level of 50mg/100ml (the legal limit for safe driving in many countries including Scotland).^[13] In addition, evidence from across shift-working industries shows that working long shifts in succession (eg blocks of seven nights) increases the risk of fatigue and errors, with the risk increasing the more shifts worked consecutively.^[8,14]

Junior Doctors in Scotland are currently required to not exceed 48 hours per week averaged over a 26 week reference period. The 48 hour figure takes account of annual and study leave. This requirement relates to the European Working Time Directive and is separate to the contractual limits provided in the New Deal. There is some evidence that the reduction of hours worked to this average is likely to have contributed to improved patient safety, with 33% fewer medical errors in one (relatively small) study.^[15] This study assessed the intervention of a 48 hour average working week alongside a number of other evidence-based interventions to improve safety and reduce fatigue, suggesting that reducing working hours alone does not provide the solution. Although the study did not explore this issue, trainees reported a reduction in Educational Opportunities.^[5] Studies from the US appear to indicate improved safety with reduced working hours, but this was in the context of reducing working hours from 85 to 65 per week.^[16–18] Interventions which reduce the working hours of Doctors in Training have not been shown to adversely affect patient mortality, cost of care or the rate of readmission to hospital.^[19] Overall the available evidence is limited by variable definitions of “long hours” and differing methods of assessing fatigue levels. The optimal duration of a working week for doctors is unknown.

Personal Health Effects of Fatigue

Over the long term, working long hours, shift work and night work adversely affect the health of workers^[20,21]. Specific effects include increased risk of cardiovascular disease^[22,23], primary sleep disorders^[24], becoming overweight or obese^[25], and developing type 2 diabetes^[26–28]. Other studies which have included hospital workers have found an increased risk to shift-working women of miscarriage and pre-term birth.^[29] Fatigue is a risk factor for burnout^[6], and working long hours may increase the risk of depression and anxiety. Female night-shift workers appear to be at an increased risk of breast cancer^[30,31], and night shift work is linked to an elevated risk for prostate^[32] and colorectal cancer^[33], as well as dementia^[34].

Other Risks for Fatigue

It should be noted that total working hours is not the only factor influencing fatigue. Shift work disrupts circadian rhythm and the natural sleep cycle^[35] especially early morning^[36] and night shift^[37] work. It is widely acknowledged that the effects of fatigue are more pronounced working night shifts compared to day shifts.^[38,39] Having short recovery times (<11 hours) between shifts, or rapidly rotating schedules (eg frequent transitions between day and night), also adversely impacts on sleep duration^[40]. “Forward-rotating” rota designs are recommended^[6,41]. Rota design and shift duration affect inpatient continuity of care^[42], necessitating more frequent information transfers between clinicians (introducing an increased risk of error) and reducing educational opportunities. Anecdotal evidence reported by members of this expert working group suggests physician continuity of care can also reduce workload and perceived stress through improving the doctor’s familiarity with a patient’s recent history.

Work conditions are also relevant to fatigue. Rest breaks taken during a shift reduce risk from fatigue^[4] but require adequate facilities including access to food and drink and the capacity for short naps overnight (<20 minutes to avoid impaired alertness of first awakening).^[41] The recent review “Caring for Doctors, Caring for Patients” commissioned by the GMC and undertaken by Prof. Michael West and Dame Denise Coia recommends all UK Healthcare Employers implement the BMA Fatigue and Facilities Charter and BMA Good Rostering Guidance.

Workload must also be considered. Excessive workload may prevent doctors from taking breaks and also increases the risk of interruptions. Decision fatigue is a recognised acute consequence of high-intensity work.^[6] Finally, a junior doctor is expected to maintain administrative and education documentation as part of their training which should nominally be completed during working hours: where workload prevents this these required tasks must be completed on the doctor’s unpaid/non-work time, effectively extending working hours beyond those rostered.

Conclusion

There is limited evidence that a reduction in working hours to 48 per week, averaged over a reference period, could reduce fatigue and resultant risks to safety. However, there are some measures which have a more compelling evidence base, for example: limiting higher numbers of consecutive long shifts of at least 10 hours, avoiding frequent day-night transitions (in either direction) and for the integration of short periods of sleep during night duties. There is strong evidence that supports the necessity of regular and adequate rest breaks during any period of work. There is no clear evidence base which points to an optimum number of working hours in any given time period or for an absolute limit on hours (without averaging) within the current evidence reviewed, particularly as they relate to medical practitioners.

A 48-hour maximum working week (without averaging) may reduce the risk of acute fatigue that specifically results from hours at work during the weeks that would previously have exceeded this limit. It would not address the other factors affecting fatigue addressed here and may in fact exacerbate them. Unless there was simultaneous and extensive system overhaul, its introduction would impact rota patterns, continuity of care and work intensity (due to the resultant reduction in clinicians at work at any one time). These factors would counteract the benefits from reduced hours to an unknown extent. As a result, we cannot confidently state that a 48 hour cap would achieve its primary goal of reducing fatigue and may even prove counterproductive, while also incurring adverse effects on secondary considerations such as work-life balance, training opportunities and team-working. Other evidence-based interventions could potentially achieve more pronounced and certain impact on fatigue, and thus clinician and patient safety, with fewer unintended consequences.

For references, see Appendix 8.

Lewis Hughes and Luke Yates