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

5. Public Partner Reflections

The primary role of a public partner on the EWG was to ensure the EWG adhered to the Terms of Reference and to provide objective scrutiny of the EWG processes. This section contains Danny McQueen’s observations in respect of these. In addition, Danny has added some thoughtful insights and suggestions on the content discussed at EWG meetings which should inform NHS leaders in taking forward the recommendations of the EWG.

Observations from Lay Representative (HIS Public Partner) Daniel McQueen

Summary concerning procedure and outcome

1. The EWG worked in accord with its Terms of Reference.

2. The other members made me very welcome and encouraged me to contribute to the discussions.

3. I was impressed by the positive attitude and active engagement of the various parties represented on the EWG. The Chairman has been excellent in facilitating focused discussions.

4. There was thorough and detailed evidence gathering and discussion of possible benefits and risks associated with the probable changes needed to achieve a 48-hour working week, without averaging, for Junior Doctors (JDs). The desk-top rota exercise undertaken at Hairmyres Hospital involving medical, nursing and administrative staff from North Lanarkshire Health Board, and EWG and NES facilitators, was comprehensive, open-minded, and proved very helpful in reviewing the draft rotas that had been prepared to explore the feasibility of a 48-hour week, without averaging.

5. I was in agreement with the conclusion that introducing the 48-hour week without averaging using existing resources would be a serious risk to service delivery and would lengthen the time required to train JDs to Consultant level. It might reduce fatigue for JDs, but other staff (Consultants, nurses, auxiliaries and ancillary staff) would have their workload increased, with the associated stress, fatigue and reduction in the quality of their lives. JD education is under the auspices of the GMC, not devolved, and so cannot easily be altered in Scotland.

6. A planned phased increase in staffing levels might achieve the desired outcome, but it would take time and funding to train and recruit the necessary personnel, from medical students through to Consultants, Nurse Practitioners and Physician Assistants. Different specialities, hospitals, and Boards have particular protocols designed to meet their service requirements locally, so it will be challenging to design national rotas and rosters that are equitable and flexible across the 14 territorial Health Boards in achieving the desired outcome of safe and effective healthcare and high quality postgraduate training for JDs in Scotland.

Personal comments as Public Partner, highlighting some of the evidence considered

1. Working week.

One surprise to me as a layperson is that much of the NHS hospital system generally works a five-day week, with reduced activities at weekends. Exceptions are the acute services, such as A&E, Obstetric, Acute Medicine, Lab services and Radiology, which run 24/7, and some special elective “catch-up” medical and surgical initiatives at weekends to reduce waiting lists. Given the high demand for routine elective services, perhaps the NHS could review how more of the facilities could be used on a seven-day basis in order to spread the workload and reduce pressure on JDs at weekends, perhaps by employing staff who would prefer to, or can only, work at weekends? This would need to include support staff, such as phlebotomists, porters, receptionists, cleaners and caterers, in addition to doctors and nurses. Other sectors in modern society have moved towards a seven-day working week, with all that entails for employees and operating costs. A patient-centred NHS should be managed for its customers, as well as its staff.

2. Shift duration and actual hours worked by JDs.

It surprises me that the hours JDs are working are not routinely recorded, although periodic “snap-shot” sampling is undertaken by managers. There is considerable evidence to show that productivity and safety decline after 10 hours of pressured working, so future rostering - in association with increased staffing levels – should explore 8-hour maximum shifts, to reduce fatigue and risks associated with working 10-12 hour shifts, currently required to fill rotas with existing staff. Patient safety and staff wellbeing would be enhanced by eliminating long busy shifts, particularly when there are rota gaps and it is not feasible to take breaks. Modern IT systems used in other sectors enable the actual hours worked to be logged automatically via non intrusive methods such as door entry cards, personal ID badges with a built-in microchip, or via mobile phone tracking apps. Such information would be very useful for HR and Health & Safety purposes, as well as service design in the NHS. Knowing the actual hours worked, the breaks taken, the time spent on service provision, education & training, and time off work might be controversial (Big Brother risk), but if the information was generally unintrusive to collect, used anonymously and not linked to individuals’ remuneration, it could be a progressive development that might help enhance the wellbeing and retention of JDs.

3. Fatigue and rest.

Evidence shows that it can be difficult for JDs to take statutory breaks during busy shifts, and that this leads to fatigue, stress, and sometimes to ill-health or resignation (drop-out). A reason for not taking breaks is the lack of appropriate cover, particularly when working on rotas with gaps (insufficient staff to fill the roster), the heavy workload associated with hospitals running at or near-capacity in caring for an ageing population, and the desire to serve their patients. The latter altruism is commendable, but it could result in fatigued doctors compromising patient safety, as well as endangering lives when, for example, handing over patients to the next team then driving home exhausted at the end of their shift. JDs and their managers seem prepared to ignore statutory breaks, albeit unwillingly, and staff not taking mandatory breaks seems to be an acceptable risk. This is in marked contrast to other groups in society with stressful jobs having potential risk for endangering the public, such as airline pilots, air traffic controllers, train, HGV and coach drivers. In these jobs adequate cover is provided for breaks, working hours are monitored and penalties are applied to employers and employees for breaching the rules. When cover is not available, the coach/truck/plane is delayed until the operator has taken the designated break.

4. Facilities.

Some hospitals reportedly have no provision for staff catering or rest rooms for use during night shifts, and others do not allow a nap to be taken during 12 hour shifts at night/weekend. This is not in accord with the professional guidance given to JDs working such shifts, namely to reduce fatigue by taking a 20 minute nap during the shifts and to ensure that a hot meal is taken mid-shift (e.g. see recommendations from the Royal Colleges of Physicians and Anaesthetists). It would seem appropriate in terms of risk reduction and safe working by JDs to ensure that breaks are taken, thereby reducing fatigue and risks. This could be done in parallel with reviewing the 48 hour week. Some extra costs are likely, and use of locum doctors, Nurse Practitioners, Physician Assistants and senior medical students to provide temporary cover during on-site breaks could be explored.

5. Patient safety and Information Technology (IT)

The 12 or 12.5-hour shift is recognised by JDs and other workers as regularly being linked to fatigue near the end, when crucial hand-over information concerning patients is passed on to the next shift. Patient safety is potentially compromised by reliance on verbal communication. The process would benefit from patients’ notes being available online, with IT systems automatically flagging concerns or test results that may have been overlooked or misunderstood during the end of shift verbal hand-over by tired doctors.

6. Supervision and team communication.

One stressful feature for inexperienced JDs working with reduced support as a consequence of rota gaps or weekend night shifts is the reluctance and limited ability to communicate securely with senior colleagues who are on-call at home. I was amazed to find that methods used by my grandchildren to share information by mobile phones, such as exchanging text and pictures instantly via WhatsApp, is generally disallowed or discouraged in the NHS on the grounds of General Data Protection Regulation (GDPR) and patient confidentiality. It should be possible to devise a secure encrypted equivalent to WhatsApp for the NHS for sharing information confidentially, as is already the case for emails via NHS.net . Secure phone communication (telemedicine) between colleagues via pictures or short videos of patients, scans, or lab results would increase efficiency for JDs and their senior colleagues, whilst also improving JD’s decision-making, confidence and training, thereby reducing stress, stress-related absence from work and potential

career abandonment - whilst enhancing JDs’ wellbeing and morale. Encrypted interchange of objective information (evidence) within and out-with hospitals is, I understand, already available for a few specialities (e.g. radiology), and extension to most specialities and hospitals would be a relatively cheap way of reducing the stress and fatigue associated with the high workload reported by JDs. On-call supervisory senior doctors would also benefit by dealing with more JDs concerns from home, reducing the tiring need come in to the hospital.

7. Conclusion.

From a lay perspective, improved team-working, communication, rostering and staffing can reasonably be expected to reduce the stress and fatigue being experienced by JDs, whilst also enhancing their education, training and wellbeing. This in turn would improve healthcare for patients in Scotland. Such an outcome is arguably achievable quite rapidly as a priority, with minimal risk and cost, while the inevitably longer-term process of achieving the 48 hours maximum working week for JDs, without averaging, develops in tandem.

Daniel McQueen