Underpaid, underappreciated and under pressure

Junior doctors in England will ballot for industrial action next month. Action would focus on restoring pay after years of real-terms cuts but – as doctors tell Ben Ireland – there are many other serious issues which undermine morale

Location: England
Published: Monday 12 December 2022
junior doctors' protest pay

‘Junior doctors can’t take proper breaks,’ says Vassili Crispi.

‘We sit in front of our computer to work, eating a sandwich, sometimes holding a bleep.’ Dr Crispi, a foundation year 2 in West Yorkshire, explains: ‘Even if you’ve told colleagues you need a break, you’ll probably be bleeped.’

Many NHS hospitals’ staffing levels are so stretched now that junior doctors cannot escape bleeps on a five-minute rest to grab a coffee or snack. These are doctors who invariably work beyond their contracted hours, often at unsociable times, for as little as £14.09 an hour.

‘That private time to regenerate is taken away from you,’ says Dr Crispi, currently on a neurosurgery rotation having started his F1 year during the peak of COVID. ‘It’s frustrating. The effect tiredness has on doctors, let alone on patients, is underestimated.’

Research by the BMA’s population health team found 46% of trusts have taken no action to ensure trainees get uninterrupted breaks overnight (except in emergencies), a recommendation of the BMA Fatigue and Facilities charter in 2018. Of those trusts, 89% have no plans in place to introduce this policy.

Dr Crispi CRISPI: ‘Private time to regenerate is taken away from you’

Doctors being sufficiently rested is critical for patient safety as well, night or day. Dr Crispi says: ‘Even a 10-minute break is important to recharge, and I think patients would agree.

'You don’t want to see a doctor when they’ve worked overnight with no break and seen dozens of patients. You want a well-rested doctor with a clear mind.

‘I’ve worked with colleagues who have not taken a break after eight to nine hours of a 12-hour shift or even none entirely. They’re very different people to when they started their shifts.

'We’re constantly seeing patients, putting up with high levels of stress, coping with emergency, making sure we’re prioritising the right patients, always running around – it uses up a lot of energy, mentally and physically.’


Interrupted breaks

Norwich-based core surgical trainee Roshan Rupra says: ‘I’ve yet to have an uninterrupted break during my four years as a junior doctor. In an ideal world there would be enough staff available to cover. Then uninterrupted breaks would be feasible.

‘If I have lunch at all, it’ll be a working lunch. I end up having a shake because it’s fast, cheap and I can have it on the go. I’m frequently on the go.’

Kerrie Thackray, a specialty trainee 4 registrar in Hertfordshire, says: ‘As one of the more senior doctors overnight, I try to say how important it is to get a break to the foundation year doctors because there’s very little that can’t wait 20 minutes.

‘But I probably don’t often practise what I preach because we’re all so conscious of just how much needs to be done. You might have the emergency department phoning because patients have been waiting eight hours. You don’t know what’s waiting, so it’s often easier to carry on and try to deal with what’s in front of you.’

Poor facilities in hospitals’ doctors’ messes are bringing down morale among juniors.

The effect tiredness has on doctors, let alone on patients, is underestimated
Dr Crispi

Dr Crispi says many doctors’ messes must be improved to offer ‘a base’ with ‘a sense of community’ to ‘meet your colleagues, unwind, rant, have something to eat or try to sleep a little bit when that’s possible’.

Rooms might include rest areas, a kitchenette, toilets and computers for ‘some isolated space away from busy clinical areas’, he suggests. ‘As an F1 or F2 you change hospitals every few months,’ he adds.

‘By the time you’re embedded it’s time to move and you’re a brand-new doctor needing to acclimatise again. We need an area where we belong.

‘In one trust with hundreds of junior doctors there’s a mess the size of a bedroom with a collapsed sofa and another sofa propped against the wall because it’s unfit for purpose, a toilet with a flush that doesn’t work, leaking showers and one without a lock.

‘If you’re lucky enough to get some sleep on a night shift there are usually two solutions. One is to put chairs together and the other is to lie on the floor. Sometimes people end up using pillows taken from somewhere on the ward. Some facilities are better than others, but that’s quite common. It’s not the glorious profession many of us envisioned, let alone what the public think.’


Time out

Dr Thackray adds: ‘When I’m on as the medical registrar, I’ll be getting bleeps from all over the hospital. It’s very difficult to take time out because there’s nowhere to rest.

‘We know taking a 20-minute rest, or having a coffee, improves your cognitive ability significantly. But where? You could maybe squeeze in a 20-minute nap, but it would be in a brightly lit room on the floor or a sofa, and you’ll probably get repeated bleeps.’

Dr Rupra says: ‘Doctors often don’t have a protected, separate space or, if they do, it’s not clean. It’s normally two or three uncleaned sofas and a pillowcase that’s been on for months.’

He points out ‘some hospitals don’t even have a mess’, while others have off-site facilities, which are ‘not feasible’ for doctors carrying bleeps. ‘I’ve seen some pristine messes,’ he says. ‘But that’s because no one is using them.’


Supporting each other

Juniors say it can be tense to eat in the same canteens as patients when hospitals are so stretched. ‘I’ve heard of doctors being booed in waiting areas, so going into a canteen might not be the most appropriate setting,’ says Dr Rupra.

‘There should be a separate area for doctors.’ The 2020-21 NHS People Plan called for trusts to offer ‘safe spaces for staff to rest and recuperate’.

It also recommended each trust hires a wellbeing guardian ‘to look at the organisation’s activities from a health and wellbeing perspective and act as a critical friend’. But the BMA’s research found 45% of trusts had not and, of those, 66% had no plans to.

kerrie Thackray THACKRAY: ‘It’s very difficult to take time out because there’s nowhere to rest’

Dr Thackray says she has ‘never heard of’ wellbeing guardians. ‘Sometimes we get encouraged to do wellbeing activities and e-learning about how we can manage our time and stress, but that feels like giving us another thing to do without dealing with what’s causing the wellbeing issues,’ she adds.

Dr Crispi is ‘not surprised’ trusts haven’t followed through on the recommendation and says junior doctors have taken the role into their own hands by looking out for each other. ‘One of the strongest measures we’re taking is calling out when colleagues haven’t taken a break,’ he explains.

‘Someone else telling you that you need a break can be a stronger prompt. Quite often you don’t take a break because the workload is so significant.’

Dr Rupra set up a wellbeing hub in his trust off his own back during the height of COVID.

‘I wonder if I was supposed to be the wellbeing guardian at that point?’ he jokes. He queries if such a role would work in practice, adding: ‘Junior doctors are very aware wellbeing is extremely important. We know we need to look after ourselves, but the job doesn’t lend itself to that.’


Inescapable bleeps

The BMA’s research found 32% of trusts had taken no action to implement a peer-to-peer mentorship programme. Of those, 50% reported no plans to introduce such a policy.

Dr Thackray did receive support when returning to work after seven years out to raise her children and found it ‘really helpful’ and ‘quite refreshing’. But she says she is ‘particularly concerned’ about foundation year doctors who have been ‘shifted around the country’ on rotation and ‘don’t have social support’, lacking access to mentors who she thinks would be ‘really valuable’ for them.

Dr Rupra says he was asked about mentoring someone but was not offered a mentor himself. Instead, he has approached seniors for informal guidance and joined the Association of Surgeons in Training. ‘That’s one way doctors are plugging a gap their trusts aren’t fulfilling,’ he says.

It seems obvious that studying the ever-evolving subject of medicine is easier without interruptions. However, according to the BMA’s research, 29% of trusts have taken no action to ensure bleep-free training for junior doctors and, of those, 21% have no plans to.

Doctors often don’t have a protected, separate space or, if they do, it’s not clean
Dr Rupra

Dr Rupra says: ‘Bleep-free training is essential to staying up to date with our knowledge.’ The issue, he says, is ‘who else is going to hold the bleep?’

He explains the number of gaps in junior doctor rotas means a more senior doctor would be required to step down to cover if juniors are in protected training, ‘and, if they did, they might have to give up their current duties and patients would lose out’.

‘The reality is that doesn’t happen, and junior doctors are forced to hold a bleep and either not attend their teaching or attend while being interrupted and thus not learning. This means junior doctors feel less valued and will either try and remediate that work in their own time or leave the profession. And that’s really sad.’

Dr Thackray says a hospital she worked at relies on junior doctors’ personal phone numbers in place of bleeps, and they ‘sometimes get bleeped when they’re not on call’ as a result. She agrees ‘bleep-free training is important’ for career development.


Hot meal access

Access to hot food might be seen as a basic right for employees regardless of profession. But the BMA’s research found only 18% of trusts have fully implemented the recommendation from its Fatigue and Facilities charter that staff should have access to hot meals 24/7.

‘Junior doctors are working incredibly long shifts without provision,’ says Dr Thackray. While she says ‘the overnight provision of food has been better in recent years’ she notes ‘some trusts only have vending machines with microwave meals’.

One of Dr Rupra’s colleagues brought in a microwave because ‘the department was so sick of not having access to hot food’, but that still required health and safety clearance.


In one trust with hundreds of junior doctors there’s a mess the size of a bedroom
Dr Crispi

Car-parking charges are considered a de facto tax on doctors – and can be a risk to patient safety when those doctors are on call. But 71% of trusts have no plans to implement on-call designated parking spaces – something the NHS committed to as part of the BMA Fatigue and Facilities charter.

Dr Thackray, who pays £40 a month for a staff permit, says there is ‘almost never’ a space when arriving for a twilight shift, so she ends up paying £10 extra a day to park in patient spaces to avoid a dark walk from an area where residents get frustrated at the overflow, and to save time so she is not late home for childcare responsibilities.

Many hospitals have removed provision of parking spaces for on-call doctors, adds Dr Rupra, who says: ‘If a doctor were not to attend their on-call shift because they couldn’t find or afford parking, I would be very worried they might get called to a meeting and be scapegoated. The hospital wants us to work, but isn’t helping us to.’


A bitter taste

The combination of these wellbeing issues leaves junior doctors tired, frustrated and seeking change as part of the upcoming industrial action ballot.

They feel paying staff more fairly will lead to fewer rota gaps and help begin to ease some of the wellbeing pressures outlined by the BMA’s research. At the moment, as Dr Rupra says: ‘No one has time to look after their own wellbeing. Covering your own work is difficult but doing two people’s jobs is near impossible. We don’t even get a thank you for that, it’s become an expectation.

‘Junior doctors take a lot of pride in our work. We want to do it to a really good standard, which requires time. If it’s not done to a good standard, you don’t progress in your career and you’re stuck. The system is built so that we don’t get time to look after ourselves.

‘It leaves a really bitter taste in my mouth to have to say these targets are not realistic. The sad truth is the system we’re working in has so many rota gaps and leaves doctors not feeling valued. A big part of that reason is because we’re not being paid what we feel is correct. It’s a domino effect.’

Roshan Rupra RUPRA: Bleep-free training is essential – but who else would hold the bleep?

Dr Crispi adds: ‘No matter how dedicated you are to your work, it’s affecting your personal life. Our days off are practically just spent recovering.’

But he is hopeful of change. While doctors may historically have been ‘reluctant to talk about ourselves and our mental health’, Dr Crispi says ‘a new generation of doctors are more willing to bring up these discussions and speak up when things aren’t going well’. 

  • Forty hospital trusts responded to the survey conducted by the BMA’s population health team



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