College perspective: 48-hour maximum working week (without averaging) for Junior Doctors in Scotland

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 a 48-hour working week, without averaging.

Junior doctors currently work on rotas which are designed to meet an average 48-hour working week; however, this means there are weeks of longer hours balanced by weeks of shorter hours.

The EWG concluded that:

  • Moving from current rotas to 48 hour maximum (without averaging) rotas can only be achieved with an increase in the percentage of Junior Doctor working time spent out of normal working hours.
  • One unintended consequence of this would be greater fragmentation of Junior Doctors’ working time, with potentially detrimental impacts on their experience of daytime, team-based routine and elective care. The reduction in normal daytime working would result in a loss of training time for Junior Doctors, according to the EWG.
  • There would be adverse service impacts of reduced Junior Doctor availability during normal working hours, with the likelihood of reduced service activity unless additional staff can be recruited.
  • There is a significant risk in some specialties that the GMC required curricular outcomes could not be delivered within the approved indicative training time for each specialty due to the loss of normal working time. This would result in a complex issue of having to extend indicative training time to Certificate of Completion of Training either for individual Junior Doctors or systemically for all trainees in specific specialties.

Commenting, Dr Marion Slater, Fellow and Member of Council said:

The College recognises that within current systems and the current financial envelope, it would be highly challenging to introduce a national pilot for a 48 hour non-averaged working week at this time. We welcome the Rota Checklist and Flow Chart developed by NHS Education for Scotland, which are a significant step forward and should be commended.

An emphasis on staff wellbeing is always welcome, however we must ensure this is followed by swift and decisive action with clear accountability for the institution of recommended changes. The provision of appropriate rest facilities and access to hot food and drink around the clock must now be mandated as well as a clear line of cover by colleagues during breaks, to allow adequate and uninterrupted rest.

As noted in the report, the restructuring of postgraduate training to allow more trainees to attend larger training centres could be detrimental to the recruitment and retention of doctors, particularly in more remote and rural areas. Additionally, there are very valuable learning opportunities in remote sites that would be lost. The wider context of significant gaps at consultant level across specialties and across Scotland must also be considered to ensure medicine remains an attractive, sustainable career and to ensure the high standards of patient care our people deserve.

Dr Jonathan Guckian, Co-Chair of the Trainees and Members’ Committee added:

We recognise and welcome the attention paid to junior doctor fatigue and the consideration of innovative means to take on this immense challenge. While COVID-19 has changed the landscape in healthcare, it has not changed the fact that before the pandemic, we required more trainee doctors. This report emphasises this idea, discussing the long-term need for investment in trainee doctor numbers.

Such radical changes are needed to fill future consultant posts, to help adapt to increasingly complex demands on the health service and to address the oncoming crisis surrounding medical fatigue and wellbeing. Whilst the report identified that such investment will take time and resources, this is a worthy cause demanding a long-term view.

We also note the recommendations for improving junior doctor wellbeing. These changes, such as access to hot food, decent facilities and safe rotas are not innovative or novel. Such recommendations should not be aspirational, rather they should be mandatory and implemented immediately. We cannot construct the supportive, enabling and compassionate culture this report refers to without turning such words into action.