The junior doctor contract is causing a lot of controversy for many reasons, but I would like to focus on safeguarding the number of hours worked. The government seek to remove the existing safeguards contained in the current junior doctor contract.
The current system for junior doctors involves a rota monitoring system. Rotas are designed to be compliant with the current rules. Once every set period (typically 6 months to a year) that rota will undergo a monitoring process to ensure the hours worked are within the defined safe limits. When a monitoring exercise is undertaken, the hours actually worked will be analysed against the contracted hours and the safeguarding rules. These rules are broadly defined as
91 hour maximum working week, 48 hour average over 26 weeks, maximum 5 hours without a break
So what happens if these rules are broken and the hours worked significantly in excess of the contracted hours? The hospital will have to pay a fine and in addition, pay the doctors on the rota for the additional hours they worked. Sounds fair. However, it is a system beseeched with problems. Firstly, the junior doctor working has to report individual breeches of the rules to their consultant. Yes, their consultant. The one who fills their appraisal, their assessments and ultimately their references. In addition, the 26 week average which is used for the calculations allows for much gaming of the system. A series of small cuts here and there. No time for handover, annual leave being included in the calculations and questionable start and finish times to name but a few.
Many junior doctors have observed they do not work within the confines of these safeguards, however, they see these safeguards are vital to ensure the hours worked do not become ridiculous. Rather than a strict safeguard on hours, they act as reducing and controlling force and hence are deeply valued.
Studying other safeguarding systems in other safety critical industries, it is clear to see that the current system for junior doctors is unfit for purpose. If we study lorry drivers' hours safeguarding
1 - the data collection is autonomous, continuous and independent (the use a tachograph, an electronic device to collect accurate, unbiased data)
2 - the enforcement is independent (via the driving and vehicles standards agency)
3 - the powers of the enforcing agent are immediate, regulated and safety orientated (they have the power to stop unsafe practices)
4 - the employee and the employer are both punished financially for breaking the rules
So what are the lorry drivers' hours limits
50 hour maximum working week, 45 hour average over 2 weeks, maximum 4 1/2 hours without a break
Note the significant difference. 2 week average, not 8 as proposed by the government, not 26 as it is now, but 2 weeks. This results in a more steady level of activity without the peaks and troughs of the current junior doctor current system.
In the new junior doctor contract, the removal of the existing safeguards is arguably the point of greatest contention. I would suggest that rather than removing them, we should be embracing and strengthening them. Would you want, a surgeon to operate on the 71st of 72 hours? No. What about the 59th of 60 hours. Again probably not. How about the 49th of 50 hours... Ok, getting better.
There will be a problems in developing this. Firstly, what system to use? Technology has many solutions for this, many seem fit for purpose on initial inspection. Swiping ID cards, geolocation, near field communication. These are not expensive, technically difficult or hard to implement. Secondly, what fines to use? Although it may be a bitter pill to swallow, placing fines placed solely on the hospital is not fair or robust. Doctors may need to be subject to financial penalties for working beyond hours for the new system to work. Anything less could be viewed as complicit. And lastly, the biggest problem, there are just not enough doctors in the UK. Within the EU, the UK is the 24th out of the 27 member states for doctors per patient. So, what comes first, the volume of the work required or the safety of it. I would argue safety as the number 1 priority.
True safeguarding will involve changes to how junior doctors work. There is enough evidence to suggest the current junior doctors working patterns are driving them out the country before this new junior doctor contract. In the last year, 40% of second year doctors did not continue their training. We are not certain where they went and if they will come back. The time is ripe to make that positive change for the better.
It is clear to me that as the NHS is continually being pushed to deliver more for less, these safeguards become increasingly important. If we are to place safety in the heart of this contract, then it must take precedence over other issues. The question is, are the medical profession ready to embrace the change and is the government ready to listen?