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Last year, I undertook a job on a busy medical ward. As is so often the case, I found a rota that was running almost entirely on the goodwill of the staff who worked it. It was tough. Now I won’t deny there were good aspects: the team of juniors I worked with were amazing; the consultants were kind; and I learnt a lot. But as the months progressed we found ourselves gradually ground down by the pressure of work.
The FY1s on two-month placements would count down their remaining days at the top of their handover sheet, and the rest of us exception-reported vicariously through the solo FY1 … we’d leave the ward at 6pm - fuelled only by the morning’s coffee and whatever leftovers we could wolf down in the brief lunchtime teaching - eagerly pushing the solo FY1 to submit a report, so that someone, somewhere would know that yet again, we’d taken no break and would be returning home late.
And yet, the story I tell here is so common as to be considered normal, par for the course, expected. We’ve all been there, we’ve all done that, and so why complain? The NHS relies on the goodwill of its staff. This is true, it will probably always be true, but what people often forget is that my goodwill is valuable to the NHS, my goodwill has a cost, and my goodwill should be recognised. Recognised routinely, recognised as par for the course, recognised for the impact it has on my training, and recognised for the opportunity cost – the missed dinners with friends, the times that we weren’t able to spend time with the ones we loved, or to tuck children in at bedtime. They have value.
The new rostering guidance for junior doctors in England, agreed with NHS Employers and released last month, takes us one step closer to this recognition. The agreement reached emphasises the right that our contract lays out in stating that all periods of overwork should be exception reported. This has a dual benefit; not only do we give value to that extra time given, but we actively and dynamically provide data on how well the rota is working. If an exception report truly is exceptional, then no harm - goodwill continues, but is valued. If, however, the exception is becoming the norm, employers can see this, and the accumulating cost of the continued goodwill and grinding down of existing workforce can trigger positive changes to rotas and staffing levels.
The contract says that exception reporting informs the employer of when day-to-day work varies significantly and/or regularly from the agreed work schedule. Sadly, since the implementation of the 2016 contract, we’ve received some reports of local employers trying to dictate what a significant or regular variation might be – suggesting that short late stays or single missed breaks are not worthy of reporting. This guidance confirms our stance that it is not the place of the employer to tell you what is significant in terms of a breach. To me, 15 minutes could mean a missed train home, broken plans, a late bedtime. A missed break or teaching opportunity could mean a later lapse in concentration, or a failed ARCP. If we are honest with ourselves, each and every late stay, missed teaching opportunity or skipped break, has an opportunity cost; it has value, and it is significant. As such, it is now agreed by all parties that these should and must be reported.
I don’t want to work in an NHS without goodwill, and when my patients are sick, or a family needs to talk, I will stay late, I will miss lunch, I will forego teaching; that will not change. But what must change is the way in which this cost is valued, acknowledged, and appreciated. The added value here is that by creating an accurate record of how often and when such things are happening there is a chance, given time, that rota planning and staffing levels can be adapted, and smarter rostering can seek to minimise the frequency and severity of these exceptions.
So, my plea today to junior doctors is to value yourselves, your time, your teaching and your goodwill. Exception report.
Find out more about the rostering guidance for junior doctors in England
Zoe Greaves is a GP trainee in the north-east of England and a member of the BMA junior doctors committee
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