Under pressure

This month Paul Gray, the Chief Executive of NHS Scotland, wrote to health boards across the country telling them to go easy on junior doctors. The remaining seven rotas which require them to work seven nights in a row must be phased out, and working hours monitoring must be simplified, the letter states.

“We expect that by 2016 no junior doctor will work more than seven day shifts in a row,” it says. All junior doctor rotas prepared by NHS boards are submitted to the Scottish Government for final approval.

The advice is being welcomed by Dr David Reid, who chairs the BMA’s Scottish Junior Doctors’ Committee, although it will be a challenge for the Government and NHS employers to meet the targets, he says. “They’re aware of all these issues and they’re trying to address them, and trying to attract people to live and work in Scotland, so things are going along the right tracks,” he tells Holyrood.

Awareness of the working conditions of junior doctors has been high since the death of Dr Laura Connelly who was killed in an accident on the M8 after seven intense weeks of long hours in her first job in 2011.

Reid became aware of the pressures of the job soon after commencing training, but stuck at it, despite it not being his first choice of career. “I wanted to be an astronaut, of course. But that was not realistic. I think everybody who is a medical student or at school knows doctors work long hours, and I think they expect that. I don’t think school or university will prepare you for actually how arduous the working patterns can be at times,” he remembers.

Reid is uncomfortable with the description ‘junior doctor’. “It’s a misleading term, I think. I think the term ‘doctors in training’ is more useful. It encompasses all doctors in training grades from the point of graduation until the point of becoming a consultant or a GP. So it’s not just newly qualified people coming out of university, you’ve actually got people in there in their mid-30s and 40s as well.”

Under-filled rotas have led Health Secretary Alex Neil to call for attracting more medical students and junior doctors from overseas. He said he was “not fussy” where they came from, so long as they spoke the language, were well qualified and could do the job, at the annual NHS Scotland event in Glasgow in June.

Reid says it is an “interesting proposition”, but questions whether the under-filled posts would be attractive to anyone, regardless of where they come from. “The jobs which are predominantly under-filled are high pressure, often high service posts which are unattractive because, among other reasons, the work/life balance is too far skewed towards work. Take emergency medicine, for example, you work fixed rotas with horrible shift patterns, working back shifts with a high frequency of back shifts in comparison with other hospital doctors who earn the same amount of money,” he says.

Foreign doctors can take a while to adapt to an NHS environment, Reid says, and it can be difficult while they bed in. “And in particular, I think Scotland presents a language barrier to a lot of people. I’ve got a couple of African colleagues at the moment who really struggle with the Coatbridge and Airdrie dialect!” he says.

Scotland will also be competing in a global market. Australia, which offers an average working week of 38 hours and better pay, often attracts British doctors to spend a year or two down under to get experience, he says.

Meanwhile in Scotland, both doctors and managers are not recording working hours properly, he says, which adds unnecessary barriers. “We don’t generally choose to stay longer than we need to, it’s usually because of a clinical need, which can range from a consultant having a ward round at five to five, versus someone taking unwell on the ward, and it’s not done out of willingness to be there, often it’s because they’re required to be there to care for patients.”

Rotas are averaged out over six months, which leads still to regular 90-hour weeks in Scotland. Most of the boards Reid has worked in have already got rid of seven night shifts, including his current employer Greater Glasgow and Clyde. There have been instances where he has “been there, done that, got the tee shirt” when it comes to working seven nights in a row, and he admits he felt “like a zombie”.

“I think all night-shift workers must have the same feeling. You get a horrible feeling between four o’clock and six o’clock when your body is telling you desperately to go to sleep, and you’re trying to stay awake, and you’re seeing patients. I actually think sometimes, after prolonged periods of night shifts, when you get to the sixth or seventh night shift, you’re actually unaware of how tired you are. It is dangerous.”

Although it is “certainly not a new problem”, the pressures on hospital doctors have changed, says Reid, even in the last six years. “If you speak to consultants, they’ll say, ‘back in my day I worked, like, 20 days in a row’, but the work has changed. Patients are more complicated, hospitals are certainly busier, and I think it would not have been uncommon in the past to sleep while you were on night shift because you were on call, it wasn’t a full shift, you weren’t expected to be awake in the hospital all night. Whereas now it’s an intense period of time you’re working.”

A&E, in particular, has become more complicated, he says. “I think it’s become busier, the patients are sicker, the patients have more problems, they don’t just come with one thing; they come with two or three problems.”

As well as a renal trainee, Reid’s acute speciality sees him doing periods in hospital as the medical registrar, who can act as the first port of call for all patients in the hospital. It is a role he describes as “busy and challenging” because of the demands both day and night, being pulled “left right and centre”. The Royal College of Physicians has done some work into why the role is unattractive.

The work/life balance is not just hampered by shifts though, Reid says. “The problem I suppose with medicine is it’s not just the day job, you also have to try and buff up your CV somewhat to progress and get other jobs. So often a bit of research or audit is required in most jobs to progress. Also to prove you’re doing personal professional development. In an ideal situation, that would be done in work time, but more often than not, you stay late after work to do that, or do things at home.”

Given the increasing pressures and the difficulty boards will have implementing the rota changes, would Reid advise youngsters to consider a different career?
“I would still encourage people to do medicine. It’s a very rewarding and fulfilling career, and you get to make a huge difference to people’s lives. That is very satisfying. The rotas and their design will change. It has to change. I wouldn’t put that as a thing to dissuade young people from doing medicine.”

Reid’s predecessor as committee chair is involved in negotiations for the new doctor contract, and although the UK Government rejected the NHS pay review recommendations and the Scottish Government awarded the pay rise, Reid is hopeful the BMA will still be able to secure a four-nation agreement. “We feel it’s in the benefit of junior doctors we have a four-nation contract, just because of the way we all move around between the four nations as part of our training. We’re optimistic we’ll be able to reach a deal about that one. We’ll just have to see what’s on the table at the end of the day.”

The uplift in pay in Scotland and not in England will require the Scottish one “to be tartanised a bit” when it comes out, he admits. If the work/life balance is addressed, will Reid be fulfilling his childhood dream and spending his new free time and money on a space tourism flight? “I’ve gone off that idea now. It seems like an awful lot of hassle to become an astronaut, or to get a job with Virgin Galactic or something.”