6. Conclusions and recommendations:
The EWG conclusions and recommendations will be presented in the following sections:
1. A 48 hour maximum working week (without averaging) for Junior Doctors cannot be safely achieved within current service models and staffing establishments in NHS Scotland
2. Service and staffing changes necessary for future implementation of a 48 hours maximum working week (without averaging) for Junior Doctors in NHS Scotland
3. Recommendations for improving Junior Doctor wellbeing and minimising fatigue in the workplace
4. Implementation and next steps
Section 1: A 48 hour maximum working week (without averaging) for Junior Doctors cannot be safely achieved within current service models and staffing establishments in NHS Scotland:
Following analysis of the quantitative and qualitative data collected during the EWG programme of work, all EWG stakeholders agree:
1. A 48 hour maximum working week (without averaging) for Junior Doctors cannot be safely implemented within existing service and education models and staffing establishments
2. It would be unsafe and potentially counterproductive to undertake a workplace based pilot study of 48 hour maximum working week (without averaging) rotas using current Junior Doctor establishments in NHS Scotland
In reaching these unanimous conclusions, the EWG concluded that the impact on service provision, continuity of care for patients, training and education for Junior Doctors and the workload for other staff groups in the service would create unacceptable risks to patient and staff safety and disruption to the provision of healthcare.
Furthermore, the best available 48 hour maximum working week (without averaging) rotas for Junior Doctors would result in a fragmented working pattern with the potential to actually increase the risks of fatigue in the workplace, thus negating the purpose of the intervention.
Section 2: Service and staffing changes necessary for future implementation of a 48 hours maximum working week (without averaging) for Junior Doctors in NHS Scotland
Having concluded that a 48 hour maximum week (without averaging) cannot be achieved within existing service and education models and current staffing establishments, the EWG considered a number of more radical options for pursuing this policy objective. In order to deliver a successful outcome, all options need to address key issues identified in the rota modelling and Hairmyres University Hospital visit to ensure:
- Continuity of patient care and maintenance of service delivery
- Appropriate prioritisation of daytime working hours for Junior Doctor to deliver training and education curricular requirements and involvement in multidisciplinary team based care
- Adequate out of hours working to deliver curricular requirements in relation to emergency care
- Best practice rota design to minimise fatigue risk
- A whole system approach to manage the impact on other staff group
The EWG considered five options that had the potential to meet these requirements, all of which would have major implications for management and resources:
1. Significantly increasing the Junior Doctor establishment in NHS Scotland
2. Restructuring the postgraduate medical training model in Scotland from a per capita distribution of trainee doctors across Health Boards to a smaller number of training centres. The greater concentration of trainees in training centres would permit rotas to be designed that achieved the 48 hour target without detriment to service provision and training and education in these centres
3. Extending the indicative training time for postgraduate medical training programmes across Scotland so that the reduced weekly hours of work and training to achieve the 48 hour target were compensated by additional years of training to complete the curriculum requirements and achieve the Certificate of Completion of Training (CCT)
4. Reducing the reliance on Junior Doctors for 24 hour acute care provision by using other staff groups (including consultant and Staff Grade, associate specialist and specialty (SAS) career grade doctors, physician associates and advanced nurse practitioners) to staff out of hours rotas (together with a reduced commitment from Junior Doctors who must have some exposure to out of hours working to complete their curricular requirements)
5. Reducing the number of 24 hour acute care rotas provided across NHS Scotland through service redesign and amalgamation of rotas
The benefits and risks of each of these options are summarised in table 1 in Appendix 9.
The EWG did not consider any of these options to be desirable or to offer practical means of achieving the 48 hour target giving the current service and staffing pressures in NHS Scotland. Further in-depth analysis and a formal risk assessment would be essential pre-requisites before embarking on a strategy to implement a 48 hour maximum working week (without averaging) through any of these routes. In the absence of evidence of the effectiveness of these interventions or the potential for unintended consequences across the whole system and other staff groups, a formal pilot study and evaluation would be desirable.
Options 1, 2 and 3 all require system-wide policy decisions for implementation and could not, therefore, be piloted and evaluated on a regional or specialty basis. Options 4 and 5 might offer potential solutions in some service settings and could be piloted and evaluated on a regional or specialty basis but the challenges to be overcome should not be underestimated and the costs of implementation would be significant.
Options not suitable for regional or specialty pilot and evaluation:
Option 1: increasing the Junior Doctor establishment in NHS Scotland is not realistic given the lack of available trained doctors who could be recruited. Initial modelling suggests that an increase in trainee doctor numbers of around 30% would be necessary but unlikely to be achievable given the difficulties in recruitment to the current junior doctor establishment. Creating the necessary workforce through increased medical student numbers would require a minimum lead time of 8 years.
Option 2: changing the educational model to 4 or 5 specialist regions or centres has some attractions from the educational perspective but the service impact on regions and centres that lose training posts combined with the adverse impact on long term recruitment and retention of medical staff would more than negate the potential benefits in terms of Junior Doctor hours.
Option 3: Extending the indicative training time for individual doctors in training would have an unpredictable impact on the attractiveness of training in Scotland for Foundation doctors applying for Specialty or GP training. Furthermore, the risk of the GMC withdrawing educational approval is considered too great without detailed discussions and an agreement of support from the GMC.
Options that could be piloted and evaluated:
Options 4 and 5 would potentially be more realistic approaches to achieving the objective of a 48 hour working week (without averaging) for Junior Doctors while ensuring service continuity and patient safety. However, it would also require significant lead-in times to develop and train the workforce and manage the service changes.
These approaches could be combined by redesign of out of hours service provision (reducing the numbers of 24/7 acute care rotas) and by employing and utilising other staff groups. It is, however, essential that the ‘fatigue risk’ is not simply transferred from Junior Doctors to other staff groups by increasing out of hours workload without robust workforce planning and an appropriate increase in staffing establishment.
It should also be recognised that there will not be a single solution or formula that can be successfully applied across all 70 or so postgraduate medical specialties, all the diverse geographies in Scotland (including remote and rural settings) or across different clinical service models in 14 territorial Health Boards.
Delivering a maximum 48 hour working week for Junior Doctors in NHS Scotland would, therefore, require locally developed and implemented solutions, probably utilising a mixed economy of the solutions identified above, and phased in as the required workforce is developed.
The EWG did not reach a consensus position on further options to implement a maximum 48 hour working week (without averaging) for Junior Doctors in Scotland. The stakeholders did agree that:
3. There is no evidence that implementing a 48 hour maximum working week (without averaging) for Junior Doctors in Scotland will per se reduce fatigue and its associated risks
4. Robust, evidence-based recommendations on how to achieve the policy objective of a 48 hour maximum (without averaging) working week for Junior Doctors in Scotland would require more extensive consultation with service and education providers in NHS Scotland, additional expert input and potentially further research and piloting of different models in specific regions and/or specialties.
5. The challenges, costs and timescales for implementing a 48 hour maximum working week (without averaging) for Junior Doctors through any of these routes should not be underestimated. All potential solutions based on the interventions described in this section are likely to take a minimum of 8 years to implement
Section 3: Recommendations for improving junior doctor wellbeing and minimising fatigue
The EWG was not able to identify actions to safely achieve the specific Scottish Government policy objective of a 48 hour maximum working week (without averaging) for Junior Doctors in the foreseeable future. There are, however, evidence-based interventions known to combat and prevent fatigue and the consequent risks to patient and staff safety that could be implemented in NHS Scotland (NHSS) in more realistic timescales.
The EWG recommendations are based on analysis of the evidence summarised in section 3.4 (Evidence of Fatigue and relationship to hours of work and rota design). The synergy between the EWG conclusions and key findings (especially key recommendations 2 and 3) of the GMC Report: ‘Caring for Doctors Caring for Patients’, make an even more compelling case for prioritising these changes over interventions designed to achieve the 48 hour working week (without averaging).
In addition, the proposed changes in rota design, (specifically introducing a limit of 4 long shifts in any 7 days) will have the added benefit of reducing the total hours of work in some rotas. This may be considered an interim step to reduce the hours of work in the longer term.
Recommendations (in addition to current policies complying with the Working Time Directive) that could be implemented across all Health Boards, training centres and specialties with an established evidence base:
6. Improving Facilities:
- Overnight rest areas for all night shift staff
- Sleeping facilities for post-night shift staff who are too tired to drive home and/or arrangements to be driven home
- Provision of nutritious food and drinks for all night shift staff
7. Improving Rota design
- Sharing best practice in ‘intelligent’ rota design across NHS Scotland Health Boards utilising IT programmes and the PCAT Improvement process- see Appendix 10
- Implementing the revised educational approval process developed by NES (section 3.2)
- Minimising frequent transitions between day and night shifts and prioritising forward-rotating (day-evening-night) rota designs
- Restricting consecutive days of long shifts (greater than 10 hours) to a limit of four in any seven days
- Provide adequate recovery time after night shifts to re-establish normal wake/sleep patters
- Minimising extreme variations in working week hours by reducing the numbers of zero days and excessive hours worked within individual weeks in a rota; recognising that there will be specialty specific requirements and differences in optimal rota design
- Ensuring a minimum of 30 minutes continuous protected rest and approximately four hours of duty
8. Enhancing Staff Governance:
- Provision of basic education and unit induction regarding sleep, fatigue and working nights for all night staff
- Review the recommendations of the Health and Care (Staffing) Bill (2019) in relation to implementing safe medical staffing tools to combat fatigue
- Develop a supportive culture that encourages and enables night time staff to nap during breaks to combat fatigue
Implementation and Next Steps:
The EWG are aware of innovations and areas of excellent practice within NHS Scotland in relation to many of the above recommendations. There is, however, neither a consistent set of standards nor an implementation strategy across all NHS Scotland Health Boards to establish such uniform standards to facilitate the spread of best practice.
The publication of the GMC Report Caring for Doctors Caring for Patients (November 2019) and the Scottish Government Health and Care (Staffing) (Scotland) Bill (May 2019) provide timely catalysts for developing a national approach to improve standards and outcomes in relation to staff wellbeing and combating fatigue in all staff groups. This should include Junior Doctors working non-resident on-call rotas which were not part of the EWG Programme of Work.
Such improvements would be facilitated by a policy decision to develop and implement a Scotland wide consensus approach based on the seven key recommendations in the GMC report, supported by the development and implementation of safe medical staffing tools referenced in the safe staffing legislation. This would help ensure equitable solutions across different specialties and geographies in Scotland and the sharing and spread of best practice.
Individual Health Boards would be required to generate action plans for implementation from 2020, with the ongoing support of Scottish Government Workforce Advisors.