Research carried out by the Royal College of Physicians has identified large variations in the provision of medical cover at night, with some doctors being responsible for up to 400 patients.
The study, to be published later in the year in Clinical Medicine, examined the makeup of clinical teams in hospitals in England and Wales and the number of patients for which each team was responsible. It found that, at night, doctors were responsible for an average of 61 patients, but the range was from 1 to 400. The seniority of doctor in charge of a ward also varied considerably; 63 teams reported that, on the night the survey was carried out, the most senior medical cover was a junior doctor in their first two years of training. Consultants were involved in the direct delivery of overnight care in only 6% of teams. Day cover on the ward ranged between two and 65 patients per junior doctor, with the highest ratio per doctor in Wales and the lowest in London. This reflects a much higher number of trainees in the region (in 2008 there were 1,135 specialist training posts in London compared with 146 in Wales). The average number of patients per doctor also varied considerably between specialties. Other key findings identified possible problems with junior doctor welfare and vacancy rates, including: 58% of consultants reporting an increase in sickness rates of juniors under them compared with before the introduction of EWTD rotas. The highest sickness rates were in second year trainees, possibly reflecting a loss of team working and sense of belonging in doctors a year into their training. Vacancy rates ranging from 1% of foundation level trainees (the first two years after qualification) and 8.6% of specialist trainees. As it is not mandatory to report sickness rates, this survey is the first to get independent evidence of current rates for junior doctors across England and Wales, and show that they are higher than a recent survey by the NHS Information Centre suggests. Vacancy rates are also notably higher than would be expected considering official figures, especially for specialist trainees. This may be because trainees taking time out (for example to do a research degree) are not counted in official figures, despite their absence from the ward needing long-term locum cover. Vacancies have both direct and indirect effects on service provision and potentially patient safety. Rota gaps are often hard to fill with locum staff and there are significant concerns as to the safety of some locum doctors. Dr Andrew Goddard, director of RCP’s Medical Workforce Unit, commented: “The very low number of doctors per patient at night in some hospitals raises serious concerns for patient safety and there are also worrying reports of very junior doctors being left unsupported, which urgently require further investigation. In the daytime, care for many patients is carried out by junior doctors, which limits their time shadowing more senior doctors and improving their knowledge and skills. “The 48-hour week was brought in to improve the wellbeing of doctors, and by extension prevent mistakes in patient care. The apparent rise in sickness rates of junior doctors since the introduction of the European Working Time Directive highlights the additional stresses that are being put on trainees by new rotas. “Far from benefiting their welfare, the poor implementation of the directive means that juniors are missing out on crucial support and valuable training opportunities, and patient care is being spread too thinly.”
