How much do junior doctors know about the regulations governing their employment seven years after the introduction of the Department of Health's New Deal, which sets standards on hours, rest periods, accommodation and catering?
A survey of 186 junior doctors from trusts in Northern and Yorkshire region was carried out between September and December 1997. One hundred questionnaires were sent to a random sample of junior doctors and 43 were returned. In addition, 143 questionnaires were completed by junior doctors during hospital mess meetings or unofficial visits to hospitals around the region. The sample included 46 pre-registration house officers, 60 senior house officers, 63 specialist registrars and 14 doctors who did not state their grade. There were 181 usable replies.
The questionnaire was designed to test doctors' knowledge of what the New Deal guidelines specify on contracted hours, the hours actually worked, rest periods, food provision and standards of accommodation. The New Deal was introduced in 1991 following discussions between the Department of Health, the royal colleges and the British Medical Association. At that time 100-hour-plus working weeks and 80-hour weekend shifts with little rest were common.
The regulations state that no junior doctor should work over 56 hours a week on average, although they may be present in the hospital on duty for longer. They call for eight hours' total rest overnight when a doctor is on call and working the day before and after. They specify that someone should be available at all times to deal with accommodation problems, rooms should be serviced at least three times a week, no more than two residents should be expected to share a bathroom, shower or toilet, and meals should be available outside normal hours. The guidance says vending machines and microwave meals may be used to supplement normal catering but should not usually totally replace it.
More than half (54 per cent) of junior doctors did not know whether their post met New Deal targets, and 24 per cent said their post did not meet New Deal targets.
Most (78 per cent) knew that the New Deal was intended to reduce their actual hours of work. And 80 per cent knew that contracted hours per week on a rota should not exceed 72 on average. But only 38 per cent knew that hours actually worked per week should not exceed 56 on average.
Only half (49 per cent) knew the correct rest required for an on-call rota. More detailed knowledge regarding rest periods for rotas and other work patterns was lacking. Of the 22 per cent of doctors who said that their post did meet the New Deal, less than half of those were able to correctly identify the rest periods required for a rota.
Most doctors (78 per cent) knew that the New Deal required that accommodation should be of a certain standard. And 62 per cent knew that hot fresh food available out of hours was also a requirement. Most (69 per cent) also knew that the New Deal included guidelines on inappropriate duties for junior doctors. But 67 per cent of doctors thought that the New Deal included regulations on training, which is incorrect. No doctor was able to answer all the questions correctly. The majority of doctors (65 per cent) did not know if their trust had a New Deal implementation group.
Circular EL(97)2, issued in January last year, required local implementation groups to be set up, and that they should normally include the medical director, junior doctors, consultants from all specialties, the chief nurse and facilities managers.
The circular also set out the requirements for ongoing monitoring of work intensity of every post and full implementation of the New Deal in each trust. It introduced a system of accreditation to take effect from 1 April 1997. Under this, trusts which have achieved a satisfactory standard in applying the New Deal can be signed off by the regional taskforces. Every six months the trusts must fill in a return, stating the number of junior doctor posts and whether these comply with New Deal regulations. Each trust must have its returns validated by a junior doctor. The validating junior doctor's main role is to say whether or not the trust has accurate monitoring systems to be able to fill in the returns accurately, and has the right to amend the returns and put 'noncomplying' if they are certain they do not meet the requirements. So a knowledge of the requirements is vital.
The accreditation process also requires trusts to provide details of canteen opening times and arrangements for weekends and bank holidays. They are required to provide information on the food available, the times, the restocking process and microwave access. They are also required to carry out satisfaction surveys among junior doctors every six months.
At the start of the New Deal, the government set up taskforces in each region to advise on, and oversee, its implementation. Most juniors (66 per cent) knew this. But some thought the British Medical Association or royal colleges were responsible for overseeing implementation.
A key part of the monitoring process is that it is validated by junior doctor representatives. Juniors need to be involved in implementing the New Deal, not least to avoid changes made by others who may not have such a deep knowledge of the workings and requirements of a department. Juniors can and should use their knowledge of the New Deal to work with trusts in achieving accreditation. Yet this is often difficult as juniors swiftly come and go. There are now two trusts in this region, including mine, that have employed junior doctors in a non-clinical capacity solely to work on the New Deal and its implementation. These initiatives have proved successful.
Activities undertaken at Bradford Hospitals trust include a trust-wide ongoing monitoring programme covering work intensity, hours of duty and the non-hours New Deal issues of catering, accommodation and skill-mix. When monitoring work intensity doctors carry diary cards when working out of hours for a minimum two to three-week period. The work is then assessed and analysed by computer.
The results of the survey of what juniors know of the New Deal are disappointing, but not surprising. The survey shows that most juniors (65 per cent) in this region are unaware of the existence of their trust New Deal implementation group, although most have one.
A survey of junior doctors in trusts in one English region found the majority did not know whether or not their post met Department of Health requirements on hours and conditions.
Most did not know that average hours worked per week should not exceed 56.
Most of the acute trusts had groups to implement these New Deal regulations. But almost two-thirds of junior doctors were unaware of these.
Ignorance of the New Deal by junior doctors and other NHS personnel could hamper accreditation of trusts.