How to fix doctors’ rotasBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4367 (Published 27 June 2019) Cite this as: BMJ 2019;365:l4367
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We read the article on ‘How to fix doctors’ rotas' with interest. We recognise many of the challenges identified with doctors' rotas. In particular that high-quality rotas cannot be guaranteed by solely relying on the contractual/regulatory framework (often referred to as “contractual compliance”).
The Scottish Government has developed a supportive quality improvement process for trainee doctors’ working environment, the Professionalism Compliance Analysis Tool, ‘PCAT’, to address these areas.
PCAT is based on three domains: Patient-centred safe care, quality of training, and trainee health and wellbeing. The PCAT improvement process involves the local team (trainee lead, training and clinical service leads) in the design of an internal trainee survey based around the three domains, as well as the gathering of factual information regarding the rota and working environment. The survey is conducted anonymously and this along with the factual information gathered is used to produce a Red-Amber-Green (RAG) report, including qualitative data for the department. This report is then discussed with the whole department, vitally including trainees, training leads and clinical management. At this feedback meeting, key areas are identified for improvement using QI processes with established timelines. In this way, trainees are engaged, empowered, are listened to and see real change as a result of their feedback. The process, data and report are owned by the department and not used as a scrutiny tool, though departments are encouraged to share good practice through a feedback report. Thus PCAT also identifies areas of success, allowing these to be recognised and celebrated within departments and organisations and shared externally to disseminate good practice. Collation of individual good practice feedback is being developed into an accessible library of good practice to share nationally.
PCAT facilitates the structured gathering of rich information which is detailed and specific to individual departments while being mapped to GMC and Deanery surveys. Using PCAT as a framework, departments have been able to identify and improve on many areas including those discussed in the article such identifying how many doctors are needed in a department to provide a high-quality rota, solutions around study and annual leave.
PCAT has been widely used in Scotland. PCAT is supported by the Royal College of Anaesthetists and endorsed in the Royal College of Surgeons Edinburgh Report ‘Improving the Working Environment For Safe Surgical Care. [1,2] PCAT is supported by NHS leaders in Scotland and is becoming routinely embedded within all Health Boards across the country through continued use of the tool and the delivery of local and national training workshops. The systematic use of PCAT across all specialty rotas is being facilitated through NHS Board Human Resources, Medical Staffing and Medical Education Directorates and promoted as a policy position by Scottish Government to improve the working lives of doctors in training.
PCAT is offered as a freely available structured consistent improvement process to address this wide range of demoralising and damaging issues raised in the article. Further information and detailed implementation pack can be obtained from email@example.com
Dr Andrew C Pearson, Specialty Registrar O&G NHS Fife. Scottish Clinical Leadership Fellow 2016-17
Dr John R Colvin, Senior Medical Advisor, Scottish Government and Consultant in Anaesthesia and Intensive Care Medicine, Ninewells Hospital Dundee.
Acknowledgements: PCAT has been developed with contributions from Scottish Clinical Leadership Fellows in Scottish Government Health Workforce in particular including Dr Reem Al-Soufi, Dr Myra McAdam, Dr Robert O’Donnell, Dr Karen Lindsay, Miss Emily Broadis, Dr Kate Arrow, Dr Chris Sheriden.
1. Paterson-Brown, S., McGregor, R., Robb, L., Baggaley, A., Hartley, A., Hill, J., Dobie, V., Griffin, M., Parks, R., Al Soufi, R., Hutchison, J. Improving the working environment for safe surgical care. A discussion paper from the Royal College of Surgeons of Edinburgh. The Royal College of Surgeons Edinburgh. 2017 https://www.rcsed.ac.uk/media/415574/rcsed-working-environment-web3.pdf
2 A report on the welfare, morale and experiences of anaesthetists in training: the need to listen. The Royal College of Anaesthetists. December 2017. https://www.rcoa.ac.uk/system/files/Welfare-Morale2017.pdf
Competing interests: No competing interests
Current junior doctor rotas across the NHS trusts are challenging with multiple gaps across all grades. Throw in short term sickness, the European working time directive and fulfilling teaching / training requirements and we have a recipe for any rota coordinator to consider a change in career. I do sympathise with the plight of the rota co-ordinators and staffing personnel across the NHS.
A few years ago we made a step change in managing junior doctor rota led by the Medical director, having a designated consultant and a departmental manager across the division to support the rota co-ordinator. Devolving the day-to-day management of ward juniors to respective speciality registrars, junior doctor whats-app groups and an internal bank of locum grade doctors was also created to effectively manage problems arising regarding junior doctor rota. Prompt review of CVs for short term gaps by consultant colleague, facilitating cross cover arrangements across specialities or overseeing quick turnaround of business cases where needed were facilitated by the presence of departmental manager and consultant input.
Over time, we have found this approach extremely successful in managing our rota gaps and facilitating teaching and training for our junior doctors. Pre-emptive planning for change over days, bank holidays and holiday season is planned and adequate preparations are made to staff the wards and facilitate teaching for our juniors. This concerted effort has undeniably made a huge difference to the daily nightmares experienced till recently.
Competing interests: No competing interests
I believe the main question is not just about "how to" fix the rota, but "what needs to be fixed."
I understand the difficulty for both the rota coordinators and doctors to deal with insufficient resource and work scheduling. I learnt about mutual respect from the Canadian healthcare system. For instance, in the medical residency programs in Ontario, Canada, policies state that requests must be submitted at least 4 weeks in advance of the requests start day of the vacation.  In return, the rota coordinator must confirm or deny within 2 weeks of the request. If denied, alternative vacation times must be offered within 2 weeks. That is a fair system to both sides.
On the contrary, in the UK, it is common that rota coordinators ignore vacation requests, and deny requests without offering any alternative solution. I heard of junior doctors being requested to pay for their locums when being off sick. If rota gaps lead to patient harm, the rota coordinator can simply take no responsibility. It would be the doctors who take the blame for these system failures.
I understand the dissatisfaction of senior doctors being “stepped down” to do more junior work because of rota gaps. However, no one should say they are "too senior to complete a task." An inpatient is always admitted under a consultant, who is supposed to be the most responsible provider for the patient. Nevertheless, during rota gaps, there could be no one to complete clerical duties such as documentation and discharge summaries. Facing these situations, seniors could dump work to a junior person in another team or the patient's GP.
It is not just the rota, but the NHS vacation policies and co-workers' mutual respect and that must be fixed first.
 Wilkinson, E. How to fix doctors' rotas. BMJ 2019, 365, l4367, 10.1136/bmj.l4367.
 Professional Association of Residents of Ontario (PARO) Top Contract Questions: Vacation & Other Leave. http://www.myparo.ca/top-contract-questions/#vacation-otherleave (accessed Jul 7, 2019).
 Clarke, R. Cheap, undervalued, expendable: junior doctors in 2017? BMJ 2017, 358, j3651, 10.1136/bmj.j3651.
 Sharvill, N.J. Discharge summary information: more than DVT warnings needed. Br. J. Gen. Pract. 2017, 67, 157-157, 10.3399/bjgp17X690125.
 Yeung, E.Y. When the words 'handover' and 'prioritise' are overused. Br. J. Gen. Pract. 2017, 67, 300, 10.3399/bjgp17X691649. Available online: https://doi.org/10.3399/bjgp17X691649.
Competing interests: I have been paid for working as a physician, but not writing this letter.
Our current situation is spiraling out of control. I agree that the heart of the problem lies in an understaffed NHS.
It is drilled into us at medical school that prevention is better than cure. All these solutions are temporizing measures and do not address the underlying problem.
Training programmes are understaffed, leaving trainees to do the work of multiple doctors, which means more service provision and less actual training. Entering a specialist training programme therefore becomes less appealing.
Meanwhile locum agencies offer doctors more money to do the same job with the added bonus of flexible working hours.
I wonder if we ended inflated locum rates, would this encourage more doctors into stable training jobs? The money saved from paying locums could be invested into achieving adequate staffing levels which would lead to increased rota flexibility.
Competing interests: No competing interests