Better rota planning
In the last twelve months I have worked in A&E, paediatrics and general practice in two different parts of the country. In theory, work schedules (rotas) should be released six to eight weeks in advance, but they are often late and are subject to last-minute changes.
I’ve received desperate requests for shift swaps from colleagues – for example, who have been rostered to work on their own wedding day – and it is common practice to be swapped onto nights or called back in to work at a moment’s notice.
It would be a great help to have the contact details of rota co-ordinators before starting a job. Accommodating leave requests in the rota rather than relying on individuals to swap would be much fairer. And distributing rotas with the advised six to eight weeks’ notice would help doctors in advance would help with planning other commitments. In future, using dedicated rota software would avoid human error.
Shadowing before my first job in psychiatry prepared me well for that role, but not for my acute medical job four months later. I went on my first ward round not knowing who anyone was, and my ‘smartcard’ was not set up to order tests. I was fortunate not to have started on a night shift, where I would have had only the support of a skeletal out-of-hours service. It is unsurprising that junior doctors can feel isolated and unsupported.
A mandatory, local, clinically focused induction should be arranged at the start of each new rotation, with locum doctors arranged in advance to ensure all new juniors can attend. This could be supported with a departmental ‘induction pack’ – this was invaluable to me in my last job, detailing essential information about the department, shifts and computer systems.
Night shifts usually last around 13 hours for up to four consecutive days. However, quiet, private break rooms are rarely available, and when they are, staff may be charged for their use. Having a 15-minute nap during breaks has been recommended by a leading consultant in sleep medicine, but I find these difficult to achieve on a cold, unclean sofa in the doctors’ mess.
Long commutes are inevitable as training deaneries cover vast geographical areas, and 50 per cent of anaesthetic trainees have had a near miss or accident when driving home from a night shift.
Quiet, clean rest rooms should be available for staff to help avoid dangerous fatigue overnight, and staff should be encouraged to use these rooms after a night shift if they do not feel safe to drive home due to tiredness.
Junior doctors working out of hours are contacted through a ‘bleep’ system, so that they can be reached anywhere across a sprawling hospital site. Answering a bleep requires interrupting workflow, finding a hospital phone, and calling the displayed extension number – by which point the bleep-sender may have left.
This system makes it impossible to prioritise work – while attending a cardiac arrest I was once bleeped to re-write a drug chart and prescribe an antihistamine.
‘Bleep screening’ senior nurses, who triage job requests to appropriate members of staff, have an invaluable role to play out of hours and could be more widely adopted. Portsmouth Hospitals NHS Trust has employed bleep screening, and sends jobs to clinical staff via a smartphone system rather than by bleep, halving the number of incidents putting patients at severe or moderate risk of harm in the first year of implementation.
Junior doctors rarely work regularly with the same on-call teams, and due to the short length of rotations they often feel poorly integrated within the multidisciplinary team.
I have often felt physically and mentally drained after managing multiple unwell patients, but it is hard to ‘shut down’ to get restful sleep before returning to work 11 hours later. Informal breakfast debriefs at the end of a run of nights could allow teams to decompress, reflect and air anxieties.
Work from the Fund has already identified frontline difficulties that erode staff morale and has noted that more could be done to draw on the experience of junior doctors, who are well placed to compare and contrast practices in different hospitals. But – to quote from the report – 'this requires trust leaders to genuinely value junior doctors’ insights and to challenge the hierarchies and tribal divisions that are longstanding barriers to teamworking’.
I hope this blog highlights some of the opportunities at a local level to make meaningful improvements to junior doctors’ working lives, despite the wider macro-political and economic climate.
The national selection stuff came in from the USA and was crowbarred into the NHS. It has some benefits, like you aren’t able to shoe-in your relatives for jobs and it’s less discriminatory than other systems such as panel interviews.
But consider this: If you have candidate A who scores top in the country, they get first choice of job. Let’s say they live in City X but that year there is no job in City X. They can’t wait and reapply next year anymore because the system won’t let them apply more than about twice, or else it will say they’re too far out of med school and into their career. If that happens they either have to become a clinical fellow (non-trainee pathway which means you can’t be a consultant and get treated worse) or do GP where the rules aren’t as strict.
So candidate A reluctantly choose to take the job at city X, moves her whole family and starts a new life in that place.
Now Candidate B came second. Candidate B lives in city X but that job is taken now by candidate A. So B gets his second choice which is city Y. He has to move his whole family and go to city Y.
Candidate C came third. Candidate C lives in City Y. She can’t have city Y because that job is filled by Candidate B who didn’t really want it in the first place. So candidate C goes to city Z.
Candidate D…etc, etc, etc. You can see where this is going – nobody gets what they want, everybody is left unhappy and every doctor is forced to uproot their family and go to a place they never wanted to work!
Once there in their jobs, all these candidates know that they can (a) rarely be eligible for a deanery transfer to get out and (b) never leave the specialty and reapply (c) never move to another specialty unless they become a clinical fellow or do GP!
The changes suggested in the article above are small-fry. I know a doctor who was in his thirties, with kids, forced to have a long distance relationship. He was alone on the other side of the country away from his family. I know another who had to uproot the whole family to move to Northern Ireland for her job in a competitive surgical specialty. Apparently this is standard in the NHS. Imagine doing that to anyone else who had to work in a job where their morale and performance mattered. No wonder we have some miserable docs kicking about in the UK! I moved to Australia, half of the docs here are from the UK – so many came here the Aussis recently turned off the tap to stop letting them all in! I think the UK has now had to do the opposite and opened it up to applicants from all over the world to apply to boost the numbers!
I couldn't agree more with the comment from Marcelle Le Gros above.
Deanery transfer rules, along with national selection rules are a nightmare. E.g. you can never reapply to a specialism if you ever leave it, once you're on one "pathway" it's almost impossible to move sideways to another specialism or even go back to the start in another specialism (the only one you can really do that for is GP - the rest lock you out).
National selection randomises doctors to unsuitable locations all over the country and then deanery transfer rules being so strict traps them there. It destroys families and it destroys careers. It is absurd if you consider it applied to any other industry.
It would be very easy to sort this out - go back to the situation we had before, where doctors could apply for jobs as and when they came up, where there was no penalty for staying in a hospital acquiring experience and then applying when you were ready.
At the very least add on to the deanery transfer rules something like "you can apply for a transfer to pursue a specialist interest". Not this current lock-in situation we have now.
Overnight morale would go up.
I have been following the developments with doctors' burnout in the NHS closely (for example in this article https://www.theguardian.com/society/2020/jan/27/third-of-uk-doctors-rep…).
As an NHS patient and mother of a surgical trainee who works in the NHS, can I please bring offer my opinion as to one reason why doctors burn out?
The extremely strict rules on "inter-deanery transfer" are inhumane and archaic, and rather akin to indentured servitude.
My son was moved, with his family, to a part of the country he did not know for his training. He desperately wants to apply for a deanery transfer but, despite having what I would consider fairly good reasons, he is ineligible to even be considered.
If you look at the webpage for transfering deanery (https://specialtytraining.hee.nhs.uk/nationalIDT) the whole tone is negative and makes it clear that it is almost impossible to apply. For example, one criterion to be eligible is:
"Criterion 1 - The trainee has developed a disability as defined by the Equality Act 2010 (see below) following the acceptance of an offer of a training post, for which treatment is an absolute requirement and where the treatment, care or social requirements can only be carried out in the geographical area the trainee has applied to relocate to, as confirmed by a report from their Occupational Health Physician, GP or their medical specialist." (https://specialtytraining.hee.nhs.uk/portals/1/Content/Resource%20Bank/…). Page 7.
We have a situation where doctors are farmed out across the country to places they never wanted to go, to work in teams who don't know them, and if they want to move due to bullying, wanting to be near family, research interest, their partner having to be somewhere for work, etc etc, it is almost impossible to do so with the current 'cannot-do-ism' built into the system.
If you did away with this and allowed doctors to apply for jobs in the normal way by submitting their applications to advertised jobs, as they used to do before national selection and "streamlining" of careers was brought in around 2007, then you would almost overnight reduce burnout and increase doctors' morale. I don't want to be treated by a miserable doctor who is imprisoned in to a place he/she does not want to work due to NHS dogma and rules!
At a time when mental health is being recognised as being as important as physical health, this issue really does need to be addressed. As taxpayers we contribute large sums to training these people who, generally, are bright, committed and are certainly not "quitters", having made huge sacrifices in terms of salary, leisure time etc in order to get where they are.
Please could you look into this? Doctors' morale is also actually a patient safety issue, as the GMC identified in their 2019 report. Part of the solution could be in giving these skilled people the ability to control their own destiny
Is this a blog series? If not, it should be. I would love to read the next installment on this subject.
I agree with the other comments posted here, especially Russell Barber's. A healthcare system cannot be safe or effective when underfunded. Yet somehow there's always enough money to pay the managers 6 figure salaries! I've been an NHS doctor for nearly 10 years now, it still isn't clear what most of these managers do. Articles like this are simply a useful distraction from the core problem of underfunding and insufficient staffing.
The recent assault to doctors’ morale are the imposed new contract and the case of Hadiza Bawa where a trainee was charged for manslaughter and struck off the GMC. In this case, a trainee was unfairly held responsible for multiple system failure.
Trainees need to be paid appropriately for the hard work they do. They need to feel supported and protected whilst doing their jobs.
In order that change is effectively undertaken all levels of government and other public funded organisations need to demonstrate good management
Independent management accreditation is required to achieve this
Read the detailed case of the situation with the doctor recently struck off by the GMC and found guilty of homicide.
Do you think that this an important factor?
Great article, but many of these changes are already happening, or more accurately, should be happening but aren't due to lack of funding, staff shortages, delays in implementation etc.
The systemic underfunding of the NHS is driving staff across hospitals, from nurses and doctors to managers and ward clerks away, and won’t be resolved without a concerted funding drive to pay staff fairly for hours worked, provide basic human needs such as hot drinks, food around the clock and proper rest areas, from staff rooms with fridges to clean on call rooms where staff on nights can sleep.
None of this is complicated, but all of it costs money. With the economy growing and tax revenues likely to increase, now is the time for the government to announce a significant increase in funding to ease the current situation. Whether this happens remains to be seen.