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

Appendix 9. Benefits and risks of options for achieving a 48 hour maximum (without averaging) working week for Junior Doctors in Scotland

Table summarising advantages and disadvantages change management options for achieving 48 hour working week (without averaging) for Junior Doctors in Scotland

Option 1: Increasing Junior Doctor establishment

Benefits

• Improves critical mass of trainees in programmes
• Potential to re-establish trainees working and learning in consistent teams
• Potential to improve service delivery and continuity of care

Risks

• High cost
• Initial estimates suggest around 30% increase in trainee numbers
• Insufficient numbers of post-Foundation doctors to recruit
• Lead in time potentially 8 plus years (to include increasing medical student numbers)
• Increase requirement of senior medical staff time for educational supervision

Option 2: Restricting postgraduate medical training and education to 4 or 5 centres across NHS Scotland

Benefits

• Potential to focus resources on fewer training centres and improve quality of training
• Greater critical mass of trainee doctors learning and working together and collectively
• Increased critical mass in training centres can improve training:service balance and improve hours of work for Junior Doctors
• Potential to re-establish trainees working and learning in consistent teams
• Potential to improve service delivery and continuity of care

Risks

• Postgraduate medical training is enhanced by exposure to multiple clinical environments and geographies
• Evidence that local recruitment and retention of career grade doctors is enhanced by high quality local training experiences
• Cost of additional staff recruitment to maintain 24/7 services for clinical services which lose trainee doctors.
• Service delivery and patient safety risks if there is no workforce from which to recruit replacements for Junior Doctors

Option 3: Increasing indicative training time to CCT for individual doctors in training

Benefits

• May be an attractive to some Junior Doctors who want more time for experiential learning prior to taking up career grade posts. Recruitment to NHS Scotland training posts may be enhanced
• Improved working hours and work/life balance for Junior Doctors training in Scotland

Risks

• May not be attractive to some Junior Doctors who want to complete PG training expeditiously and move on to career grade positions. Recruitment to NHS Scotland training posts may be adversely affected
• The indicative training time for each PG medical specialty is set by the UK regulatory body – the GMC. There is a high risk that the GMC will not approve training programmes that cannot deliver the full curriculum within the stated indicative training time
• The only process for extending training time in the current UK Gold Guide is for the PG Dean to issue an ‘unsatisfactory’ training outcome. Furthermore, the time by which training can be extended is limited to 1 year with a second year only at the discretion of the PG Dean

Option 4: Reducing reliance on Junior Doctors for out of hours acute care provision

Benefits

• Reducing Junior Doctor out of hours commitments has potential to improve daytime delivery of training
• Potential to re-establish trainees working and learning in consistent teams
• Potential to improve service delivery and continuity of care
• More senior staff providing frontline out of hours service has potential benefits in delivery of care to acutely unwell patients

Risks

• Risk of transferring excessive hours and fatigue risks from Junior Doctors to other staff groups
• Lack of trained workforce currently available to provide sufficient cover on out of hours rotas to reduce Junior Doctor rostering
• Service delivery and patient safety risks if there is no workforce from which to recruit replacements for Junior Doctors
• Cost (potential 30% increase in staffing levels predicted from the pilot study)

Option 5: Reducing 24/7 acute care rotas through service redesign

Benefits

• Fewer 24/7 acute care rotas will enable regional services to increase the numbers of Junior Doctors on each rota, thereby increasing daytime hours for training and service delivery
• May be additional economies of scale across other staff groups and out of hours services
• Potential to re-establish trainees working and learning in consistent teams
• Potential to improve service delivery and continuity of care

Risks

• Will have to be bespoke solutions for different specialties and geographies. Will not be workable solution across all 24/7 acute care rotas in NHS Scotland
• Requires significant change management projects at Health Board/regional levels and unlikely to be implementable in short term
• There may be public and political resistance to service reconfiguration along these lines