This guidance gives advice on the contractual and pragmatic position when you or your employers propose that you work as a resident consultant. It is applicable for doctors working in England, Wales and Northern Ireland. We have created separate guidance for doctors working in Scotland.
What is ‘resident’ work?
‘Resident’ work is referenced in the terms and conditions of service of the consultant contracts.
In this context ‘resident’ means that the consultant would have to stay in the hospital while covering emergency duties in case their direct presence is needed. This contrasts with the usual situation that while on-call, consultants may go home when not immediately required for patient care.
The consultant contracts are clear that resident work is only performed by mutual agreement. However, increasing numbers of consultants are working on shifts, part or all of which may fall during the premium time period. There is an expectation that consultants will work with emergencies, and while they may not be scheduled for non-emergency work (including regular programmed work of consultants who normally work with emergencies) in the premium time period without their agreement, participation in on-call rotas may be required.
The concept of consultant resident on-call (CROC) may not be helpful. With the application of the Working Time Regulations to consultants since 1998, consultants are entitled to 11 hours of continuous rest in any 24. While compensatory rest can be arranged, recent legal judgments have emphasised that it should not be planned for the future but should be delivered as soon as practicable following the period of work. It is also worth noting that consultants who work lengthy periods consecutively in premium time are likely to use up most of their weekly PAs/sessions very quickly. As such, these kinds of arrangements may not be the most effective use of consultant time and resources.
Accordingly, an employer cannot expect more than 13 hours continuous work, although as with any doctor it may be necessary on occasion to work for longer periods to maintain necessary continuity of care.
Shift or resident working in an emergency
To avoid last minute uncertainty around the arrangements for consultants undertaking unplanned resident work, some LNCs and trusts have negotiated specific arrangements with clear policy on remuneration.
This is a sensible approach because working in this way is clearly beyond the specific terms of their contract. At a minimum, any activity undertaken in premium time should be recognised as such and paid accordingly. Any such arrangement should also recognise the inconvenient and arduous nature of this work. For example, consultants in Wales who agree to be resident on-call in exceptional circumstances are remunerated at three times the sessional payment at point 6 of the consultant salary scale (excluding commitment awards and clinical excellence awards) and receive compensatory rest the following day (3.8 of the TCS for Wales).
Consultants in England, Wales and Northern Ireland are obliged to deputise for absent consultant or associate specialist colleagues ‘so far as is practicable’. As the most senior member of clinical staff, consultants also have a professional obligation to ensure that the emergency clinical services offered to patients are delivered safely and effectively. Further information on consultant cover arrangements can be found here.
A written agreement is essential prior to undertaking resident work. This ensures that all those involved know what is expected of them and how such work will be recognised and paid. For very short-term arrangements, an email request and statement of recognition may be acceptable.
Where a consultant agrees to be resident, consideration should be given as to whether it would be appropriate for a colleague to be on-call at the same time. It should not be assumed that having one consultant covering the work is adequate to cope with the potential workload. In many cases, it will not be possible for a consultant to balance these two tasks effectively and safely. Consultants should also consider whether they have recent experience in all aspects of the work they may be required to do - for example, it might be inappropriate for a subspecialist in gynaecology who has not done obstetrics for a decade to deliver some O&G services.
Consultants should consider the impact resident on-call working may have on their daytime working. Depending on the work intensity, it may be appropriate for daytime commitments the following day to be cancelled. Unless the consultant has opted out in writing, their working time should not exceed the Working Time Directive limits and consultants should be aware that all of a resident’s on-call period counts as working time in the context of the Directive.
We recommend LNCs seek to negotiate such an agreement with their trusts and facilitate contact with LNCs who have already achieved good results.
Acting down – the myth
A consultant who is covering the work of a junior colleague cannot forget that they are a consultant – they do not have the option of pretending they are working at a lesser level of responsibility than they do normally. Therefore, the consultant is not ‘acting down’ - they are acting appropriately in response to the unusual circumstances they are in. It is therefore not appropriate for the consultant to be considered as working at a junior level and being paid as such. Instead, it should be recognised that they are providing consultant level care and should be remunerated appropriately.
If consultants are asked to provide resident cover because of persistently bad workforce planning beyond their control, tackling the root causes of those problems is the correct long-term approach.
Shift or resident working as a planned arrangement
Some consultants undertake shift work in premium time – this is particularly the case for certain specialties and services, such as pediatrics, emergency departments, intensive care and obstetrics. More will be faced with the need to reform emergency services in this way in the future.
We believe, where there is a need for a re-arrangement of responsibilities as a result of these pressures, the best way forward is to seek agreement on job planning arrangements to ensure that consultants are properly supported by both facilities and staff.
We are also aware that some trusts may attempt to recruit new consultants to posts which include this work in their job plans. From an employer’s perspective, this may be easier than trying to persuade or induce existing staff to take on these responsibilities. However, the view of the BMA Consultant Committee is that this not a helpful way of addressing workforce requirements. It will divide the consultant body and create potential tensions if and when those appointed to take up this work decide they no longer wish to do it and are aware that their more established colleagues are not required to carry out that work. There is already evidence that departmental conflict is often the result when such divisive approaches are taken.
Where a consultant is considering accepting a post which includes resident on-call cover in the job plan, they should very carefully consider the nature of the long-term commitment they are making. Any changes made cannot be varied at a later date without mutual agreement. One option to safeguard against this may be to negotiate a time limitation and/or a review of the resident arrangements. Members are strongly advised to seek BMA advice before proceeding to agree shift or resident working as part of their job plan.
Whether a consultant is willing to carry out this work is largely a personal decision based on a number of factors.
The key to making this successful is proper consideration of how any agreement might impact on the consultant’s work-life balance, how necessary it is to the service, and whether the terms reached are agreeable.
Where applicable, consideration will need to be given to how consultants working less than full time fit into agreed arrangements.