Hospital doctors - junior doctors’ hours
May 2006
(This briefing paper applies to the UK)
It remains the opinion of the BMA that tired doctors often do not work to their full potential. Studies have shown that the effects of sleep deprivation are similar to the effects of alcohol consumption on driving performance. It is important that the working hours of junior doctors continue to be reduced to sensible levels so that a safe, high quality service can be provided for patients1.
Current situation
Between sixteen and forty percent, depending on nation, of the UK's junior doctors are working more than 56 hours a week, or without adequate rest, according to latest Department of Health figures.
New measures to try to address the long hours worked by junior doctors were introduced in December 2000. The new contract for junior doctors (the New Deal), negotiated by the BMA and the Health Departments, sets the limits on working hours. From 1 August 2001, it became illegal for newly qualified junior doctors to be working more than 56 hours a week, or without sufficient rest. The same limit has applied for all other doctors since August 2003.
It is more than a decade since the New Deal was introduced to limit the hours worked by junior doctors and yet a significant number of junior doctors are still expected to work excessive hours. Many hospitals have been reluctant to make the necessary investment and changes in working patterns to reduce junior doctors' hours to safer levels. In some hospitals almost the entire junior doctor workforce is working hours above the safe limits. These figures are an indictment to over 10 years of inaction by hospital trusts.
For the first time, the restrictions on hours are a statutory requirement for new junior doctors. Hospital trusts must make fundamental changes if newly qualified doctors are to have any chance of working more reasonable hours. If trusts fail to reduce hours for these doctors, not only are they risking patients' lives and the health of their medical staff, they could find themselves facing legal action.
Percentage of PRHO (Pre-Registration House Officer), SHO (Senior House Officer) and SpR (Specialist Registrar) posts breaching working hours limits. The figures are based on returns for November 2003:
| England (Sept 03) |
Wales (Nov 03) |
Northern Ireland (Nov 03) |
Scotland (Aug 02)* |
|
| PRHO | 92% | 100% | 94% | 81% |
| SHO | 85% | 61% | 68% | 41% |
| SpR | 80% | 40% | 50% | 41% |
| Total | 84% | 60% | 72% | 50% |
* Total New Deal compliance in Scotland for August 2003 was 73%; figures by grade were not available.
Background
After many years of concern about the unacceptably long hours worked by UK doctors in training, an agreement called 'Junior Doctors - The New Deal' was concluded in June 1991. This agreement aimed to limit the hours of work of junior doctors in the UK, and introduced shift working for the first time.
The New Deal in some situations has changed the way in which junior doctors work. Some of these changes have been desirable, others less so. The key to successful change has been the involvement of junior doctors in designing new working patterns which ensure that training opportunities are protected and continuity of patient care remains of paramount importance.
The New Deal is a package of measures designed to improve the conditions under which junior doctors work. One of the key features is limits on the working hours of junior doctors. Different types of working arrangement, full shifts and partial shifts to accompany the previous on-call rota system, have been promulgated as part of the package, with work patterns and workload intensity being critical determinants of whether alternative flexible working arrangements are appropriate. Limits were also set on maximum continuous duty hours, minimum periods off duty between duty periods, and minimum continuous periods off duty.
Since 1 December 2000, limits on contracted hours, ie: 72 hours for an on call rota, have been a contractual requirement.
- From 1 August 2001 for pre-registration house officers, and from 1 August 2003 for all other training grades, all New Deal hours limits and rest requirements become contractual requirements.
- By the end of 1996, doctors on on-call rotas should not have been contracted for more than 72 hours, and doctors on the two forms of shift for 64 and 56 hours respectively.
- Irrespective of the working pattern, since the end of 1994 no junior doctor should actually be working for more than a maximum average of 56 hours per week. This is generally taken to mean at the workplace, at the disposal of the employer, and engaged in an actual task.
- New standards on other aspects of junior doctors' working lives, for example accommodation, catering, training requirements and the role of other staff, were agreed with the BMA's Junior Doctors Committee (JDC) in December 20002
- The European Working Time Directive applied to junior doctors from 1 August 2004.
Progress towards meeting the New Deal hours targets has been slow. The deadline of December 1996 saw the majority of junior doctors' contracted hours progressively reduced within the agreed targets. However, many junior doctors continue to be on duty for excessively long periods with inadequate rest.
Work intensity is a particular problem for on-call rotas where the specified rest periods are not met. Nevertheless, it is very worrying to note that so many junior doctors are working outside the hours limits and rest requirements of the New Deal five years after it was due to be implemented.
Trusts have a contractual responsibility to monitor regularly the hours worked by junior doctors. As part of that responsibility, junior doctors are obliged now to take part in monitoring as designated by their trust. This obligation is a contractual requirement. Each trust should have a named individual at trust board level responsible for New Deal implementation.
The BMA's Junior Doctors Committee believes that there must be significant organisational changes in hospitals. To enable them to have adequate rest, juniors must have proper support for out-of-hours work. For example, specialties with high rates of acute admissions such as general medicine, general surgery and paediatrics should have dedicated acute admissions facilities, and consultants should have time set aside to supervise and support such units.
Where the New Deal has been implemented successfully, it has usually been the case that managers, consultants, nurses and junior doctors have all recognised the need for change, and have collaborated on developing solutions. For example, the development of 'bleep policies', often in conjunction with the appointment of senior night nurses, has reduced night calls to junior doctors in many units.
There is also a growing demand for working hours which are more sensitive to the demands of family life. The number of women doctors in the NHS is rising. If reasonable working hours are not provided the NHS will have great difficulty in retaining enough doctors to provide the service.
The BMA's Junior Doctors Committee has waged a sustained campaign to ensure implementation of the New Deal. This involved highlighting areas of good and bad practice throughout the UK and, following a series of discussions, led to the NHS Executive producing a health service circular (HSC 1998/240) clarifying the interpretation and implementation of the New Deal, in particular with regard to rest requirements for all working patterns. A further health circular (HSC2000/031) gives further clarification.
Many trusts have made real improvements and have demonstrated their commitment to the principles of the New Deal. Unfortunately there are a number of trusts which have made poor progress. The BMA has been pressing the Government to make the New Deal an immediate priority and for it to be implemented in full.
Implications of the European Working Time Directive
The European Working Time Directive (EWTD), which came into force on 1 October 1998 for consultants and other career grade hospital doctors, currently excludes junior doctors. However, agreement was reached in May 2000 between the European Parliament and the Council of Ministers on the arrangements and timetable for doctors in training to be included within the Directive. The main elements of the Directive to be applied to junior doctors are as follows:
Timetable
Date |
Deadline |
June 2000 |
Timetable set to incorporate juniors into Directive |
August 2004 |
Interim 58 hour maximum working week. Rest and break requirements become law |
August 2007 |
Interim 56 hour maximum working week |
August 2009 |
Deadline for 48 hour maximum working week. This may be extended by another interim of 3 years at 52 hours if exceptional circumstances apply |
The Junior Doctors Committee has calculated that from August 2004 the hours of junior doctor cover that will be lost each week as a result of the implementation of the EWTD will be up to 213,000, equivalent to 3,700 junior doctors working an EWTD compliant 58 hour week. Following the application of the 48 hour limit, the hours of junior doctor cover that will be lost each week as a result of the implementation of the EWTD will be between 208,296 and 476,638 equivalent to between 4,300 and 9,900 junior doctors working an EWTD compliant 48 hour week. This is the main factor that makes the EWTD for junior doctors such a huge issue.
There is a separate briefing note on the EWTD
Notes:
- There are approximately 39,000 junior doctors in the UK working in the NHS.
- The most recent figures collected by the Department of Health showed that almost half of junior doctors were still working outside the New Deal hours limits and rest requirements (eg 56 hours work per week, 72 hours on-call).
Tel: 020 7383 6223/6520
E-mail: parliamentaryunit@bma.org.uk