1. Introduction and Background
The Scottish Government is committed to make NHS Scotland attractive for Junior Doctors to work and train in, whilst ensuring they have safe and sustainable work patterns. Junior Doctor rotas must comply with the EU Working Time Regulations and the New Deal contract for Junior Doctors (2002). Additional measures introduced by the Scottish Government to improve Junior Doctors’ working lives include reducing the maximum number of consecutive working days to 7, abolishing 7 consecutive night shifts, and ensuring a minimum of 46 hours recovery time after night shifts (Scottish Government Director’s Letter (2018) 16).
Scottish Government Health Workforce, is implementing a quality improvement (QI) framework that examines the working patterns of doctors-in-training: the Professional Compliance Analysis Tool (PCAT) (Please see conclusion 7 on page 32). PCAT evaluates the rota templates and the supporting professional environment across three interdependent domains: Patient Safety, Quality of Training and Trainee Health and Wellbeing.
Working Time Regulations limit the working week to 48 hours but permit the hours to be averaged over a 26 week period. As a result many Junior Doctor rotas in Scotland still include individual weeks with very long hours of work and the associated risks of fatigue. A further commitment from the Scottish Government is the introduction of a 48 hour maximum working week - without averaging - which would mean that no Junior Doctor in Scotland worked more than 48 hours in a seven day period.
In March 2018 the Cabinet Secretary for Health and Sport commissioned an independent Expert Working Group (EWG) to explore the options and changes that would be required to achieve this objective. A chair for the EWG (Philip Cachia) was appointed in March 2018. The Chair worked with Scottish Government advisors to agree on a membership of the EWG that both ensured representation of all relevant stakeholders, and proposed appropriate terms of reference for the group.
An informal workshop was held in September 2018 at which the agreed stakeholders were invited to present key issues, benefits and barriers to achieving the 48 hour objective.
The stakeholders who contributed to this workshop were:
- The Academy of Royal Medical Colleges and Faculties of Scotland (consultant and junior representatives)
- BMA Scotland (two representatives)
- NHS Scotland Management Executive Group (two representatives)
- NHS Education for Scotland (two representatives)
- Health Board Directors of Medical Education (one representative)
Building on the workshop outcomes, the membership was finalised to include the above stakeholder organisations and a public partner, recruited through the Healthcare Improvement Scotland Public Partner programme.
Terms of Reference for the EWG were developed and signed off by the Cabinet Secretary in January 2019 (Appendix 1).
Formal EWG meetings were held in November 2018, March, May, June, September and November 2019 to take forward an agreed programme of work which makes up the substance of this report. External presentations provided information and evidence on the use of e-rostering and the Professional Analysis Compliance Tool (PCAT) as examples of best practice in rota design in NHS Scotland.
All stakeholders agreed to support the EWG programme of work while noting the following:
1. The EWG programme should initially explore options for best practice rota design to achieve the 48 hour maximum working week (without averaging) objective within existing service and educational models, and with the current Junior Doctor staffing establishments.
2. If rota design alone did not enable the objective to be met, it was agreed that more radical options (service redesign and/or substantial change in the educational model) would be required to deliver 48 hour maximum working week (without averaging). It was, however, recognised that consensus between different stakeholder groups would be difficult to achieve. Furthermore, any solution would be likely to have significant resource implications and was outwith the remit of the group.
3. The relationships between rota design and hours of work for Junior Doctors are intimately linked to other key issues, including the substantial evidence base on the impact of fatigue on patient and staff safety, staff wellbeing and quality of life. There are established UK- and Scotland- wide initiatives that will report on these broader areas. The work of the EWG should be focused on the 48 hour maximum working week (without averaging), taking cognisance of implications for fatigue and wellbeing, while avoiding replicating the work of other initiatives in this area.
4. In making recommendations, the EWG would consider and prioritise the whole system consequences of Junior Doctor rota changes, including the impact on other NHS staff groups, service continuity and patient safety.
It was therefore agreed that the EWG programme of work would consist of the following stages:
1. Design 48 hour rotas with no averaging for a variety of Junior Doctor grades and specialties using current best practice and Doctors Rostering System (DRS) computer software
2. Consider the educational implications of the rota changes through the EWG NES representatives (as per current practice in the NHS where proposed rota changes require educational approval from the relevant Postgraduate Dean before implementation)
3. Undertake a site visit to explore in depth the potential impact of 48 hour rotas on: i) Service Impact; ii) Staff and Patient Safety; iii) Employee experience and iv) Educational Quality. Evidence would be gathered from a variety of staff groups through facilitated focus groups
4. Pilot potentially viable 48 hour rotas in the workplace with the agreement of local NHS management teams. (The EWG did not proceed with this after analysis of evidence from stages 1-3 and our review of the evidence of the impact of fatigue on staff and patient safety)
NHS Lanarkshire kindly agreed that University Hospital Hairmyres would be the pilot site for this work through their Management Executive representative on the EWG.