At the time of the introduction of the 2004 contract, for most consultants being ‘on call’ tended to mean just that. They would do their routine day’s work, followed by an on call period when they might do some evening clinical work, and provide some telephone advice and support. Although there were exceptions, most consultants would have expected to achieve enough rest when on call to be perfectly safe to work the next day.
For some consultants in some specialties, ‘on call’ remains an appropriate way to describe a safe and sustainable working pattern. However for many consultants, on call, or some elements of on call has changed over the years to a situation perhaps better described as ‘on site out of hours emergency working’ (understanding that emergency encompasses both emergency and urgent care).
This has been driven by a number of factors: fewer trainees; increasing patient numbers and complexity; higher patient expectations. Where this has occurred, there are some areas and some rotas where there has been an appropriate change to working patterns to accommodate this. However many consultants are still working an ‘on call’ pattern, with an ‘on site’ workload.
Working Time Regulations and compensatory rest
Consultants are covered by the Working Time Regulations (WTR), which came into force in 1998 and are aimed at protecting employees from working excessive hours. In addition to the well-known limit of an average working week over 48 hours, the regulations also include a limit of 8 hours worked in every 24 hour period for night work, an entitlement to a weekly rest period of 24 hours every week (or 48 hours every two weeks) and 11 hours consecutive rest per day 1 .
However, just like the 2004 contract, the WTR came in at a time when for most consultants, ‘on call’ still meant just that, and the BMA reached an agreement with the UK Government that most of the WTR provisions around minimum rest periods would not apply to consultants via a derogation to the regulations, with provision instead for ‘compensatory rest’. At the time, this was a reasonable approach to avoid patient care being disrupted unnecessarily; however changing consultant working patterns mean that compensatory rest is often of little practical benefit for consultants working out of hours. This makes it important to ensure that safe out of hours working is built into consultant rotas and job plans.
Working safely out of hours
A range of consultant working patterns exist across different healthcare settings in Scotland, and consultants locally are best placed to determine what constitutes safe working in their particular context. However, we believe it is appropriate to set out some general principles for safe out of hours working:
- The first call on consultant time is clinically urgent and emergency care. Consultants should reasonably expect their health board to support them in this prioritisation in job planning discussions and in responding to the day to day variation in service demands.
- Where significant periods of intense 2 out of hours work can be reasonably predicted, consultants should not have to rely on access to compensatory rest. Rather, consultant job plans and rotas should be constructed with the aim of meeting the WTR limits and entitlements as a basic minimum. When intense out of hours work is frequent or predictable, a consultant should have an appropriate period of rest before this period of work, so that they do not start work already fatigued. They should also have an appropriate period afterwards free from all programmed activities 3 (ie not just from clinical activity), to ensure adequate rest and recovery.
- When intense out of hours work is unpredictable, it may be unavoidable that a consultant undertakes this having already completed a period of routine work. Following such a period of unpredictable work, it remains essential that they then have an appropriate period afterwards free from any programmed duties. This may require clinics, operating sessions, teaching etc to be either cancelled or covered by other colleagues, and there should be explicit contingency plans in place, supported and resourced by the health board, to mitigate the impact on routine daytime activity and patient care.
- Although there are no nationally agreed thresholds for rest following out of hours working, a consensus is emerging across a range of specialties and departments in Scotland that a consultant working after midnight should not be working the next morning, and if they are working after 2am they should be free of duties all the next day. We offer these as suggested thresholds to both guide job planning around predictable out of hours work, and to act as ‘triggers’ for rest periods in unpredictable circumstances.
- Any consultant rota that requires significant periods of night working should be designed to take into account: any necessary health protections; appropriate periods of rest; realistic ‘turnaround’ times’ before and after periods of night working to deal with the inevitable 'jet lag'; avoidance of social or professional isolation.
- All consultant rotas for covering out of hours work should build in time and space for proper handovers, when that is appropriate.
- At all times (and specifically in the context of out of hours working), consultants should urgently notify their employer when there is a reduction in medical staffing levels that impacts on patient care. The medical colleges can provide specific and expert advice on this area. It should never be assumed that two tiers of rota can be covered by one individual, nor that competencies will be comprehensively shared by differing medical staff. For example, if a consultant is asked to work ‘resident on-call’ to cover a gap in the trainee rota, it should not be assumed that having one consultant on-site will be adequate to cope with the potential workload, and it will generally be safer for a consultant colleague to be on-call at the same time.
- Consultants should be aware of the general risks of fatigue; if at any time a consultant believes they are too fatigued to continue to work safely they should take immediate action to raise their concerns. Consultants should discuss with employers, both at LNC level and in individual job planning discussions, the provision of appropriate rest facilities, both during and after periods of out of hours work, and other support where necessary, eg where a health board-funded taxi home is required following an intense period of unpredictable out of hours working.
Adopting sustainable approaches to out of hours working
The practicalities of providing safe consultant working patterns may mean some consultants spending an increased proportion of their time working on-site OOH. Consultants may be wary of such ways of working, having seen the real problems for work-life balance that trainees have faced. It should be remembered, however, that there are many different patterns of working to provide this type of cover, some much more user friendly than others. Also, the potential work and life consequences of working or driving when too tired to function properly are incalculable.
It is also important to recognise that consultants providing more out of hours work are of necessity providing less routine clinical work, with implications for elective services, which management will need to engage with and address. Consultants also have well developed specialist and subspecialist skills, and have both commitments to individual patients and established working relationships with colleagues. Maintaining all of this requires to be balanced against the increasing need for OOH services that are safe for both doctors and patients.
Different people, with different work and family commitments, and at different stages of their lives and careers, may have varying ideas about appropriate working patterns, and appropriate change. Some consultants may also have health issues which need to be considered. The consultants providing a clinical service are best placed to determine what is safe and sustainable for them and their patients, and this issue should always be clinically led, by the consultants delivering the service.
This guidance is neither prescriptive nor exhaustive. Expert advice on many of these issues is available from the BMA, from the Medical Royal Colleges, and from the medical defence organisations. The issues addressed are about patient and staff safety, about avoiding illness and burnout, and about sustainable services and rotas. As such we anticipate that groups of consultants seeking to improve the way they provide out of hours cover would have the encouragement and support of their employers in moving towards any necessary change.
1. BMA - European Working Time Directive: consutlants.
2. ie when the consultant is expected to work at a similar intensity out of hours as they are during the regular working day.
3. Consultant Terms & Conditions of Service paras 4.2.1 to 4.2.9.