The Working Time Directive, limiting the working week to an average of 48 hours, has applied to junior doctors since 2009. It should have prevented junior doctors from working excessively long hours and it should have protected them from unsafe work rotas. It did neither. Junior doctors continued to work long hours routinely in excess of their rostered shifts and under intense pressure. They also continued to work rotas, one of which was described in research published by the Royal College of Physicians as “essentially the worst possible rota that can be devised in terms of safety and sleep requirements,” which have left them feeling sleep deprived and experiencing fatigue.
The NHS claims that junior doctors’ working hours are safe and that they comply with the requirements of the legislation. The facts are that junior doctors continue to work excessively long hours which are unsafe for them and their patients. The evidence from medical research and from the lived experience of junior doctors themselves is overwhelming in supporting this view.
Research has shown that the adverse impact of long working hours and sleep deprivation equates to alcohol impairment, similar to having had several drinks. It has also shown that young subjects were more affected by sleep loss than older subjects and were more frequently involved in sleep-related accidents.
Junior doctors are frequently exposed to these risks for a number of reasons. Firstly, working multiple days in succession (as many as 10 or 12), some on shifts of 12 and 13-hours duration, with few breaks and under high intensity, proves exhausting to those having to work under these conditions. Secondly, many junior doctors are temporarily assigned to a hospital away from their home location and are unable to commit to temporary accommodation. Thirdly, public transport may not be available when a junior doctor actually finishes work and is ready to go home. These are the ingredients of a very dangerous situation if the junior doctor is tired when getting behind the wheel after a long and arduous shift.
Just how dangerous was shown in January 2017 when the BBC programmes “The One Show” and “Inside Out” tested the driving reactions of a junior doctor after she had worked a 13-hour nightshift. She experienced numerous micro sleeps, veered into a different lane multiple times, and her response times increased from 1 second to 5.5 seconds. Thankfully, these tests were carried out on a driving simulator and she was unharmed. Many of her junior doctor colleagues have reported similar experiences and near-misses in real life. Yet the NHS considers junior doctors’ working hours to be safe.
The problems arising from working nightshifts are more acute than daytime working. We are programmed to sleep at night, not work, when alertness, vigilance and cognitive reasoning are at their lowest. Night working results in loss of sleep and increased fatigue. It is easier to lose concentration more often, we have decreased ability to perform technical procedures, and more clinical errors result. There is also an increased risk of accidents and impaired psychological and physical health from working nightshifts.
It is possible to analyse shift patterns and to assess the relative risk of fatigue and of accidents and injuries which employees face. The Health and Safety Executive use the Fatigue Risk and Injury Calculator to identify dangerous shift patterns which put workers at risk of accidents and injuries and to effect changes to manage those risks. The Calculator inputs variables such as workload, the times/duration and numbers of consecutive shifts, rest breaks, the frequency of change in shift patterns, and workload intensity. It then calculates a Fatigue Index and a Risk Index for each shift analysed.
In simple terms, the more shifts worked consecutively, the greater relative risk compared to the first shift worked. The longer each shift lasts more than 8 hours, the greater the risk of an accident. The risk of an accident is greater when working a nightshift than a dayshift.
In 2006, the Royal College of Physicians Multidisciplinary Group applied the Calculator to two nightshift rotas worked by junior doctors in the NHS, one consisting of 7 Nights in Succession and the other a rota which split the nightshifts into separate blocks of 4 and 3 nights. The College then compared the results with a 12-hour industrial DDNN shift rota and another rota of 5 8.5-hour dayshifts. The rota with the least Fatigue and Risk scores was the daytime shift system. The system with the highest Maximum Fatigue and Maximum Risk score was the 7 Nights in Succession rota. The comparable scores for the 4 and 3 nightshifts were reduced slightly.
The conclusion of the Royal College of Physicians was that the 7 Nights in Succession rota “is essentially the worst possible rota that can be devised in terms of safety and sleep requirements.” The Royal College recommended that in preparing for the 2009 changes, which fully implemented the Working Time Directive, the NHS should conduct urgent research to establish the optimal rota system. Their warnings were very clear: “Three years is too long to leave unchanged those rotas involving 7 nights in succession. Even if a 7 Nights in Succession rota is popular with some junior doctors, the health and safety implications are such that an employer should impose change to a safer rota. We do not recommend its use in the NHS.”
Despite these clear recommendations and stark warnings, 7 Nights in Succession rotas continued to be worked by junior doctors long after 2009, when the Working Time Directive was fully phased-in. This was the shift rota my daughter Lauren was working when she had her accident. In her case, the 7 Nights in Succession rota was immediately preceded by 4 daytime shifts, presumably increasing the already high Maximum Fatigue and Maximum Risk scores of the 7 Nights in Succession rota on its own. Had she not had her accident, she would have worked for a total of 117.5 hours and on 12 consecutive days without a full day off. She and many other junior doctors worked shifts containing many of the health and safety factors on which the Fatigue and Risk scores are calculated, i.e.
- changing shift patterns, durations, start and end times
- rotas containing multiple peaks of activity over prolonged periods, during which fatigue and the risk of accidents increase
- the number of consecutive nightshifts and their duration.
The NHS has been aware of the adverse impact of long working hours on junior doctors and the risks which they face for many years. Instead of following the recommendations and warnings from the Royal College of Physicians, they continued to require junior doctors to work dangerous shifts and to put their health and safety at risk. How can shift rotas, supposedly designed to meet health and safety legislation, put junior doctors at such significant risk from the very fatigue and accidents the legislation was intended to protect them from? To implement dangerous shift rotas is at the very least perverse and grossly irresponsible. To then claim that they are safe is beyond understanding.
The NHS claimed that Lauren’s working hours and those of her colleagues were safe and fully complied with the Working Time Directive, despite clear evidence that they were unsafe and dangerous. Since I started my campaign, the Scottish Government has taken steps to make junior doctors’ working hours safer. Firstly, they undertook that no junior doctor would be required to work more than 4 nights in a row from February 2015. Secondly, they committed that from February 2016 the practice of junior doctors working more than 7 days in a row would be abolished. However, a Freedom on Information request in December 2016 showed that junior doctors were still being scheduled to work 12 days in a row, some working 111 hours and others 117.5 hours between days off. There were no specifics of the actual shift rotas the junior doctors were working but these hours correspond to the shifts which Lauren worked, including the 7 Nights in Succession rota which the Royal College of Physicians condemned in 2006 and recommended not be used in the NHS. The Scottish Government has made another improvement by guaranteeing junior doctors a minimum rest period of 46 hours following night shifts as of August 2019.
As welcome as these changes are, they do not resolve the fundamental issue of junior doctors continuing to work hours and shift rotas which are measurably dangerous and put their safety and that of their patients at risk. The Working Time Directive needs to be properly implemented in the NHS as an effective health and safety measure. Hence the changes which I’ve proposed in my campaign:-
- junior doctors should not work more than 48 hours in any 5-day period
- working periods should be followed by 2 days off
- actual working hours should be recorded.
I ask you to support my campaign by writing to your political representatives in the Westminster and Scottish Parliaments and Welsh and Northern Irish Assemblies. Please use the template letter I have provided in an earlier post.
The NHS has failed to implement the Working Time Directive properly. Only when it has done so will its claims that junior doctors working hours fully comply with the Directive and are safe have any credibility.