The description above attempts to give an overview of the various training requirements for doctors working in the UK. The mechanisms to ensure appropriate experience and training are gained also presuppose appropriate supervision at all stages. Whilst there has always been an understanding that complete, unbroken supervision of junior doctors by more senior ones was unrealistic, in recent years it is widely felt that raw quantity of (often unsupervised) experience has been relied on too heavily as a substitute for quality. Consultants, nominally the supervisors of the continuing education of the Junior and Middle Grade Staff on their firm, have always been obliged to balance the pressures to maintain the service against the expenditure of time in training activities. As hospitals have become more intensive places to work, the balance in the eyes of many in the training grades has tipped increasingly against supervision and quality of experience. The demands for improved patient throughput on reduced budget that have arisen with the NHS reforms have only served to strengthen these pressures.
It will also be clear from the above account that the hours worked by UK doctors 'at the coal face' are long compared to European standards, especially when the length of time in training before gaining Consultant status is considered. In fact, the current figure of 72 hours quoted above is low compared with less than ten years ago. In 1990, UK Junior Doctors were by and large working an average of between 83 and 90 hours a week, with some working as high as an average weekly committment of 104 hours (a 1 in 2 rota).
Further, the average weekly figures of yesteryear and of today hide the fact that in individual weeks a doctor will do more than the average - particularly when one or more of their colleagues on the duty rota is on holiday or sick, and they therefore must take on the absent doctor's day-time and night time duties as well as their own. 'Prospective cover' - the contractual requirement to cover such absences - has the effect of turning a 1:4 rota into a 1:3 much of the time because there is rarely a week when one of the 4 people sharing the rota is not away on holiday or study leave. In 1991, as a result of the concurrent absence of two colleagues (one on holiday, one sitting exams), I personally did a single continuous 5 day shift of 104 hours without break resident in a hospital, being simultaneously first On-Call for Orthopaedic, Trauma and Otorhinolaryngology emergency referrals for a population of 250,000 via the local ER or direct telephone referral by GPs. This single shift was as part of a week when I was present, awake and on duty in the hospital for a grand total of 136 hours in 8 days.
Payment for 'overtime' - all work done for any reason outside 9-5 office hours - was precisely zero until 1976, when a Juniors' Strike resulted in a reluctant government instituting Additional Duty Hours (ADHs). These provided a prorated payment in addition to the full basic salary, and the additional payment was calculated as the average number of extra hours worked each week (over and above the basic 40) multiplied by an hourly rate. The only catch was that the hourly 'overtime' rate was fixed at 30% of the presumed full hourly rate that applied during office hours (NOT 130%). This overtime rate therefore amounted to slightly less than the standard daytime rate for porters in the same hospital.
For many years the senior element of the profession resisted calling these night-time and weekend duties 'overtime'. It was considered 'part of the job', 'good experience' and doing it for nothing or peanuts was what distinguished the noble medical profession from other, lesser employment. In their day, of course, the radiopager had not been invented and extracting a Junior from his bed involved a porter being sent to his room. Fearsome Matrons patrolled the wards and, to a large extent, prevented less experienced nursing staff from irritating the dormant doctor needlessly. Medical Science itself was simpler and there was a great deal of difference between what was possible during office hours and what was possible at any other time. For example, the amount you could or should realistically do in 1950 for a new admission of Chest Pain in the middle of the night was considerably less than today. My father recalls that obtaining even an ECG was a day's march, requiring the patient to sit in a darkened room while an oscillating needle projected a shadow onto a moving strip of photographic paper which, when developed, became the ECG strip.
Whilst on duty, but not on the wards, our medical forefathers had a relatively pleasant time of it: most hospitals still have a Junior Doctors' Mess where on-call doctors may rest in worn-out arm chairs and watch a TV paid for from deductions out of their own pay packet, but few still have the doctors' dining hall where hot breakfasts and meals were available on request at all hours. These have all been closed because they were not economic - after all, only the doctors ever ate in them. The nursing staff, increasingly, waited to eat once they were able to go home at the end of an 8 hour shift. Similar economic reasoning is used to explain why Junior Doctors must pay to park their car within the hospital grounds (even when on call).
Accomodation in hospitals has deteriorated similarly. Most contracts for Junior Doctors are only for 6 months, so a doctor may regularly move a great distance to find the next post to further their training. Traditionally, to make these transitions smooth, accomodation has been available at each hospital on request. Part of the employment 'package' of medicine of yesteryear was that the long hours of a Junior were compensated for by the fact that the hospital fed them and provided a roof over their head. Today - even when on a 1 in 2 rota and therefore obliged to be present and sleeping in the hospital every other day - a doctor will still be offered a room or flat within the hospital as a permanent place of residence for the duration of their contract, but they will have to pay rent for that proportion of the week when they are not actually on-call. Those doctors that choose not to keep a permanent room at the hospital can share a single on-call room so that, if they were lucky enough to have a break to sleep in whilst on duty, they had somewhere to go. It was not, however, uncommon to find - when you eventually got to the room at 4am - that the sheets had not been changed since the last occupant.
A further significant but unremarked passing has been the Doctor's Bar, whose remnants usually still sit in one corner of the Doctors' Mess. Several consultants have admitted to me that, when a Junior, it was not unusual for them to have one (or two) beers from the bar whilst on duty and therefore that they were not always entirely sober whilst admitting patients. The lifestyle of doctors portrayed in 'Doctor in the House' is almost certainly a charicature of the reality of the 50s, but probably also contains a grain of truth. It is unrecogniseable to modern Juniors, except that Sir Lancelot Spratt is (of course) alive and well.
In response to a growing sense of injustice and outrage in the Juniors' Ranks, (and rumoured to have not a little to do with the fact that the Health Minister's daughter had begun to study medicine), the Government struck a deal in 1991 with the profession to reduce working hours to a contractual maximum average of 72 hours a week on-call by the end of 1994 with the added proviso that work intensity when on-call should be such that a doctor should only be expected to be actually on their feet and working for 56 hours a week on average. Jobs with high-intensity workload, therefore, should adjust their on-call rota accordingly or consider moving to a full shift.
As an additional measure (or sop to the disaffected workforce) the On-Call ADH payment was simultaneously increased from 30% to 50% for a rota, and from 30% to 100% for those working on a full shift pattern. This package was billed as 'The New Deal' for Junior Medical staff. It was supposed to address all the Juniors' woes - including standards of hospital accomodation and availability of food - but it ended up focussing almost entirely on the number of hours worked.
The principal methodology for achieving the hours reductions was to encourage hospitals to deploy their junior medical staff in new ways. Instead of the traditional 40 hour, 9-5 week with additional nights and weekends on call, it was envisaged that large numbers of doctors should move to working either full shifts, or partial shifts. An idealised partial shift entailed working normal, or slightly extended, working days for a few weeks than swapping to the night duty only for an entire week.
An additional measure was to increase the expansion in consultant numbers, with the apparent (although always unstated) aim of encouraging a move to a consultant-led service. But simple mathematical calculations suggested that, if the juniors were no longer permitted to work so many hours as previously, and no new additional junior posts were going to be created, then there was likely to be a shortfall in the number of hands available to actually run the hospital. The consultant body quickly began to complain that if anybody thought that they were going to be running the show at 4am, then you could think again.
Since the ratification of the New Deal in 1991, the overall recorded hours worked by Junior Doctors have dropped from an average of well above 83 to slightly below it. However, much of this drop occurred within the first 12 months of the initial 3 year New Deal plan and very little has changed since. There is considerable belief, and some evidence, that much of even this early apparent improvement arose as a result of massaging of the figures on paper.
Reasons for the final failure are legion, including limited enthusiasm for the implications from the consultant body, very limited enthusiasm from the Juniors for the proposed shift work patterns, complete resistance on the part of the government to pricing long hours prohibitively, and probably the most fundamental reason: the numbers simply didn't add up. Meanwhile, the nurses - who it was hoped might take on some of the more pointless nighttime duties of Juniors (such as siting intravenous lines) and so help make on-call more bearable if not actually shorter - refused outright to get involved, saying that they didn't see why they should have to help the doctors get their own house in order. Unless, of course, these new duties were accompanied by a pay rise.
Right from the outset, therefore, many observers characterised 'The New Deal' as no carrot and no stick. Its most fundamental weakness, however, was that there were too few donkeys. There were not then - and there are not now - enough trained doctors in the UK to take up the slack if Junior Doctors reduced their hours by the amount proposed. No significant reduction in the workload of Juniors can ever be achieved without either redistributing their workload to entirely different professional groups or increasing the number of doctors trained each year. Whilst increasing medical school intake is within the power of the politicians (and was announced as part of the NHS Plan package in 2000), it still takes 10 years to train a doctor. Therefore any serious plan to reduce hours must wait a decade before the necessary human resources exist to finally put the plan into practice. Unfortunately for today's Juniors the New Deal did not include any Medical School intake expansion, so the staffing problem is as bad today as it was then.
To date (Febraury 2003), therefore, it comes as no surprise to learn that the stated goals have not been reached, or that in May 1999 the government stated that it would not be able to meet the final The New Deal target of 56 hours for at least another 7 years (12 years later than promised) and would not be able to meet the new EC working time directive of a maximum 48 hours working week for at least 13 years. In fact the general EC Working Time Directive currently specifically excludes doctors in training. Instead the directive requires that doctors in training should work no more than 58 hours by 2004, 52 by 2009, with the 48 hours enjoyed by everybody else being a long term target. Note that any employee can choose to sign a document saying that they wave their rights under the directive.
Meanwhile, Junior Medical Staff continue to work long hours, often being contracted for hours within (some) of the New Deal targets, but actually being required to work longer either without additional pay or being obliged to claim the time as overtime so that it doesn't show up on the official job description.
Meanwhile, discontent in the ranks moved focus somewhat from the insoluble hours problem to the issue of the training structure itself: if we really have to work all these hours, do we really have to do it for quite so many years before we can apply for a consultant post?
In 1993 a number of political events came together:
* The Chief Medical Officer of the day, Sir Donald Acheson, retired and was replaced by Dr Kenneth Calman.
* There was considerable concern about the absence of any coherent view of how the future training of doctors in the UK should be managed within the new, more commercial, NHS.
* A Rheumatologist who had trained elsewhere in the EEC was refused the right to practice privately in the UK because he did not have UK accreditation. An appeal to the European Courts resulted in a judgement that the UK accreditation scheme was protectionist and illegal within the EC treaty, and there was a suggestion that the General Medical Council (the UK body with statutory rights and duties to oversee the training and disciplining of UK doctors) had been acting illegally by effectively delegating its statutory duty to supervise training to the Royal Colleges, over whom it had no direct control.
These events led to the setting up of a full scale review of UK training practices and structures, chaired by the Chief Medical Officer, Dr Calman. The report of this committee (known as The Calman Report) recommended radical changes to the UK training structure, which would result in (amongst other things) a shortening of the overall required training program prior to full accreditation, and amalgamation of the middle grade training grades (Registrar and Senior Registrar) into one (Specialist Registrar). Most of the recommendations were adopted, with the combined training grade being adopted from April 1996 for all Hospital Specialities. It is too early to say how successful these changes will be.
In May 1999, however, the agenda returned to the hours issue. With the BMA reporting that at least 1 in 3 Juniors still worked hours outside The New Deal limits - indeed, that the number working outside the limits in 1998 was higher than for the previous year - the Junior Doctors' Committee balloted its membership to find out their willingness to take industrial action. They were presented with choices beginning with 'working to rule' and progressing to withdrawal of labour. 90% of those that responded said they would be prepared to take some form of action. However, the response rate was only 30%. Despite this poor mandate for action the Health Secretary (Frank Dobson) offered to open discussions on rates of pay, which resulted in the pay banding system already detailed.
The legally enforceable limit of 58 hours under the European Working Time Directive comes into effect in 2004, and is likely to drive significant radical change in both typical working patterns and responsibiltiies whilst at work. These include most juniors now working on shifts (which were advocated under the 1991 New Deal, but never popular) and also juniors providing cross-specialty cover during on-call hours, e.g. one junior covering both medicine and surgery rather than one or the other in isolation.
Meanwhile the Consultants negotiating body has also begun to complain about differences in hours of work. The more hard-pressed consultants (e.g. Anaesthetists) have noticed that they are spending considerably more time at the real clinical coal face after hours than, for example, their colleagues in Dermatology. Given this increasing difference they are questioning the fairness and appropriateness of the traditional NHS pay scale that pays Consultants at the same rate, regardless of speciality.