BMA SURVEY OF CONSULTANT WORKING PATTERNS AND ON CALL SERVICES

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1 BMA SURVEY OF CONSULTANT WORKING PATTERNS AND ON CALL SERVICES Health Policy and Economic Research Unit Report author: Duncan Bland Ocber 2014 bma.org.uk British Medical Association, 2014

2 Index Executive summary... 3 Survey overview... 4 Previous BMA research in consultant working patterns... 4 Caveats these findings... 5 On call rotas... 6 On call Monday Friday... 7 On call Weekends Compensary rest NHS Employer core hours of work Planned consultant presence in hospitals Appendix Tables Table 1 Intensity category and frequency of non resident on call (including comparison with the 2013 survey)... 6 Table 2 Category A rota frequency by specialty... 6 Table 3 Category A rota frequency by NHS employer type... 7 Table 4 Frequency of calls, attendance and tal time spent at hospital when on call by specialty (Monday Friday)... 8 Table 5 Frequency of calls, attendance and tal time spent at hospital when on call by NHS employer type (Monday Friday)... 9 Table 6 Frequency of calls, attendance and tal time spent at hospital when on call at the weekend Table 7 Frequency of calls, attendance and tal time spent at hospital when on call by NHS employer type8 (Saturday and/or Sunday) Figures Figure 1 Distribution for the number of calls requiring attendance at hospital (Monday Friday)... 8 Figure 2 Likelihood of being called and required attend hospital at least once by specialty (Monday Friday)... 9 Figure 3 Frequency of sleep disturbance when on call during Monday Friday Figure 4 Distribution for the number of calls requiring attendance at hospital (Saturday and/or Sunday) Figure 5 Likelihood of being called and required attend hospital at least once by specialty (Saturday and/or Sunday) Figure 6 Frequency of sleep disturbance when on call at the weekend (Saturday and/or Sunday) Figure 7 Access compensary rest following a night spent on call when sleep has been disturbed Figure 8 To the nearest half hour, at what time do core hours begin at your main NHS employer? (by normal or high priority NHS employer status) Figure 9 To the nearest half hour, at what time do core hours end at your main NHS employer? (by normal or high priority NHS employer status) Figure 10 The 24-hour distribution of start and finish times for planned consultant shifts on a weekday (n=764) Figure 11 The 24-hour distribution of start and finish times for planned consultant shifts on Saturday (n=101) Figure 12 The 24-hour distribution of start and finish times for planned consultant shifts on Sunday (n=90) s

3 Executive summary On call Monday Friday 88 per cent of consultants reported being on a non-resident on call rota. Respondents reported receiving an average three telephone calls when on call during Monday Friday. Surgeons recorded the highest average number of calls (five). Almost half of respondents reported being called attend hospital; varying between one and six occasions. Anaesthetists (74 per cent) and surgeons (71 per cent) were most likely be required attend hospital if called. Consultants worked an average three hours when attending hospital on call; anaesthetists worked an average four hours. More than four in 10 consultants reported their sleep had been disturbed in order attend hospital on one night when on call during a Monday Friday. On call Weekends Consultants on call at weekends reported receiving five calls on average (higher than Monday Friday). Almost two-thirds of consultants on call at the weekend reported attending hospital between one and six times (higher than equivalent for Monday Friday). As with Monday Friday, surgical specialists (88 per cent) and anaesthetists (82 per cent) were most likely be required attend hospital if called. Consultants reported working an average six hours when called attend hospital at weekends (twice the number of hours for a weekday). One-third of respondents were required break their normal sleep pattern attend hospital on a night at the weekend. One-fifth said their sleep was disturbed on both nights when on call at the weekend. Compensary rest Seven in 10 respondents reported never having access compensary rest following a night when their sleep had been disturbed. High versus normal priority for seven day services There were no differences in patterns of on call work or availability of compensary rest according the priority given seven day service provision by NHS employers. Responses the survey offer tentative evidence that core hours of NHS employers giving high priority seven day services start marginally earlier and finish marginally later in a typical working day. 24-hour patterns of planned consultant presence Only approximately 1 per cent of consultants reported starting a planned shift at work outside of hrs. No more than 5 per cent of consultants were present at work on a planned shift outside of hrs. There were no systematic differences in planned consultant presence across a whole 24-hour period on weekends or weekdays regardless whether respondents NHS employer gave seven day services a normal or high priority. This is a subtle contrast potential small differences in core hours only. Demography The sample demographics for the survey are broadly in line with the wider workforce, notwithstanding oversampling of consultants in Northern Ireland (appendix). 3

4 Survey overview The BMA last surveyed a sample of the consultant membership in 2013 on a relatively wide range of issues relating workload and the current consultant contract. 1 The purpose of this 2014 survey was collect more detailed information about the rate and composition of consultant on call work. The 2014 survey also included questions on night time disturbance and subsequent access compensary rest. The survey was conducted online between 5 August 2014 and 2 September 2014 and received responses from 847 of 5,822 members registered as consultants on the BMA membership database. The sample was comprised of 5,000 members in England and all consultants in Northern Ireland, consenting receive communications. The England sample was broken down further. Seventeen NHS employers that self reported NHS England s 2013 survey of acute hospitals 2 as currently giving seven day service provision a high priority comprised 50 per cent of the sample in England. NHS employers that self reported giving seven day services a normal priority were also sampled at 50 per cent within England. Respondents employer is referred as either normal or high priority throughout the report and any systematic differences in responses identified where relevant. By sampling in this way, the survey attempted identify any differences in current patterns of on call provision and planned consultant presence according hypothetical differences in the readiness of employers extend hospital services seven days a week. Sixteen respondents the survey were not currently working and were excluded from analysis; the maximum number of respondents was therefore adjusted 831. Only the largest specialty groupings are described in the present report due their sample size. Previous BMA research in consultant working patterns In the 2013 survey of consultants, respondents were asked about the planned shifts they had worked in both plain (7am 7pm) and premium (7pm 7am) time a in their most recent full working week. In that survey, high proportions of respondents reported working at these times. This was most likely a consequence of reporting a combination of on call work gether with routine, planned work b in hospitals, rather than planned work only, as was intended by the survey. This survey also highlighted a limitation of the simple distinction between plain time (7am 7pm) and premium time working (7pm 7am) as distinguishing work undertaken in late evening from full night shifts was problematic. An additional purpose of the 2014 survey was therefore clearly delineate unplanned consultant presence at hospital such as on call work, from planned, routine attendance when a consultant will expect be working. To do this effectively, the survey asked respondents record the start and finish times of their planned shifts between Monday and Sunday of their most recent full working week. This was entirely separate from questions about work undertaken when on call. This would enable the pattern of 24-hour planned consultant presence at hospital be described for the first time by our research. This is shown on page 16. a b Under the current consultant contract, consultants receive enhanced rates of pay for work that takes place between 7pm and 7am Monday Friday and at any time at the weekend. Work in plain time (7am 7pm) is at normal contracted rates of pay. Consultants were asked report the planned hours they had worked across Monday Friday and the weekend. Planned time was defined as hours of work explicitly agreed in a consultant job plan. 4

5 Caveats these findings Given the survey response rate, sample size and the size of the consultant workforce, the margin of error for responses in the present survey is plus or minus 3 per cent for most questions. The responses this survey are reasonably representative of the broader picture in England and Northern Ireland. Where appropriate, the survey compares responses from respondents according the status of their NHS employer in relation progression wards seven day services. This binary distinction is derived from employers self reported responses NHS England s 2013 survey of acute hospitals. As such, any presumed differences in progression wards seven day services and associated relation patterns of on call or other work were hypothetical. The survey asked respondents about their time spent on call (excluding planned work) in their most recent full working week. For some respondents the number of days in which they were on call may vary. Due the necessary brevity of the survey it was not feasible capture all daily activities. The survey therefore cannot be assumed be as granular as a detailed individual work diary. The survey recorded very high proportions of respondents were working on call during a Monday Friday (85.2 per cent) or Saturday and/or Sunday (68.1 per cent) in the last week. These figures, which do not align with self reported rota frequencies, suggest that respondents interpreted questioning about their most recent working week variably: some may have reported being on call in the most recent week; and some may have reported their most recent on call activity. Further, response bias, caused by differences in the accuracy of individual recollections is not a unique artefact of this survey, although we cannot exclude the possibility that some respondents accounts of their on call work may have altered over time. Although the survey focussed on non-resident on call, it is possible that some respondents reported information relating their resident on call work. Such instances should be few however. Responses which might have indicated misunderstanding, such as extremely high rates of attendance at hospital indicative of being resident on site, were removed. The vast majority of respondents the survey were based at hospitals for their main place of work. However, a small number of consultant specialists, such as those working in academia or public health may only work at hospital sites for part of their time. 5

6 On call rotas In the previous BMA survey of consultants conducted at the end of 2013, approximately only 5 per cent of respondents reported working as part of a resident on call rota. The present survey therefore restricted questions non-resident working. In the current survey, 87.6 per cent of respondents ok part in a non-resident on call rota. Although the sample size for the current survey was smaller than in 2013 (increasing the potential for greater spread within the data), there is strong agreement between both surveys. This agreement is strongest for Category A rotas c (table 1). Of the specialties shown in table 2, respondents in paediatrics and child health reported the most frequent rota, on average (one in 7.1) (table 2). Average rota frequency was one in 8.9. There were no differences in rota frequency according the respondent s NHS employer and therefore no evidence of a difference in rotas based on current priority given seven day services. There was slightly greater spread in the data from respondents at high priority trusts but this was in proportion with the respective sample sizes (table 3). Table 1 Intensity category and frequency of non resident on call (including comparison with the 2013 survey) Intensity and average frequency on-call Category A Category B Sample size (n) 1, Mean rota frequency (e.g.1 in ) Median rota frequency (e.g.1 in ) Inter-quartile range Table 2 Category A rota frequency by specialty Specialty (n) Mean Median Inter-quartile range Medical specialties (n=138) Surgical specialties (n=114) Anaesthetics (n=106) Paediatrics and child health (n=63) Clinical oncology and radiology (n=58) All (n=597) Note: Only specialties with a sample size of at least 50 shown. Equivalent data for obstetrics and gynaecology (n=41) and emergency medicine (n=33) available on request. c In Category A rotas, it is typical for a consultant be required return immediately site or undertake interventions of similar complexity those carried out at hospital. For Category B rotas, it is more typical for a consultant be able respond by giving telephone advice and/or returning work later. 6

7 Table 3 Category A rota frequency by NHS employer type 2 NHS employer (n) Normal priority Trust (n=355) High priority Trust (n=241) All (n=597) Mean Median Inter-quartile range Note: Respondents separated in two groups according the priority given by their employing trust progression wards seven day services in the NHS England survey. On call Monday Friday The survey asked respondents if they had been on call between Monday and Friday in their most recent full working week and 85.2 per cent reported that they had (620 of 728). Respondents were then asked record the number of telephone calls they had received when on call, if any of those calls had required them attend hospital and how much time they had spent in attendance at hospital in tal. Due the uneven distribution for number of calls received, number of times attended hospital and number of minutes spent attending, median values are more representative average figures. Overall, respondents reported receiving an average of 3.0 telephone calls when on call during their most recent Monday Friday. Respondents in surgery recorded the highest average number of calls; overall (table 4). Whilst it was most likely for respondents report not being called attend hospital at all, when taken as an average, a median single attendance at hospital was reported for all but medical specialties (table 4). Figure 1 shows the tal distribution of attendances at hospital ranging from zero 15 during Monday Friday. Although almost half of respondents (48.7 per cent) reported not being called attend hospital at all, almost half (47.4 per cent) reported being called out between one and six times across the week (figure 1). Table 4 shows the average number of attendances at hospital within each specialty but it does not tell us how the chances of being called attend hospital might vary. Figure 2 shows that the likelihood of being required attend hospital at least once when called varied by specialty (figure 2). Anaesthetists had a 73.6 per cent chance of being required attend and surgeons 70.7 per cent. By contrast, medical specialties had just a 24.8 per cent chance of being called attend hospital. Respondents spent a median 18 minutes attending hospital when on call with anaesthetists recording the highest average number of minutes: 24. 7

8 Table 4 Frequency of calls, attendance and tal time spent at hospital when on call by specialty (Monday Friday) Specialty (n) Frequency of calls received (Mon-Fri) Frequency of attendance at hospital (Mon-Fri) Total time (mins) in attendance (Mon-Fri) Mean Median IQR Mean Median IQR Mean Median IQR Medical specialties (n=153) Surgical specialties (n=116) Anaesthetics (n=91) Paediatrics and child health (n=67) Clinical oncology and radiology (n=58) All (n=620) Note: Only specialties with a sample size of at least 50 shown. Equivalent data for obstetrics and gynaecology (n=41) and emergency medicine (n=31) available on request. IQR: Inter-quartile range. Figure 1 Distribution for the number of calls requiring attendance at hospital (Monday Friday) Number of calls requiring attendance at hospital 8

9 Figure 2 Likelihood of being called and required attend hospital at least once by specialty (Monday Friday) Medical specialties Paediatrics and child health Clinical oncology and radiology Surgical specialties Anaesthetics Required attend Not required attend Table 5 shows that there were no differences in on call demands between consultants employed at trusts regarded as giving seven day services a high priority versus others. Table 5 Frequency of calls, attendance and tal time spent at hospital when on call by NHS employer type 2 (Monday Friday) Specialty (n) Frequency of calls received (Mon-Fri) Frequency of attendance at hospital (Mon-Fri) Total time (mins) in attendance (Mon-Fri) Mean Median IQR Mean Median IQR Mean Median IQR Normal priority NHS Trust (n=377) High priority NHS Trust (n=242) All (n=620) Note: Respondents separated in two groups according the priority given by their employing trust progression wards seven day services in the NHS England survey. IQR: Inter-quartile range. 9

10 Respondents that were on call and required attend hospital during the Monday Friday were asked on how many nights, if at all, they were required break their normal sleep pattern ( attend hospital). Approximately equal proportions of respondents replied that their sleep had been disturbed either not at all or on a single occasion. There were no differences according NHS employer (figure 3). Figure 3 Frequency of sleep disturbance when on call during Monday Friday None One night Two nights Three nights Four nights Five nights On call Weekends 68.1 per cent of respondents reported being on call during a Saturday or Sunday in the last week (496 of 728). Respondents were asked equivalent questions those for being on call on Monday Friday concerning number of calls received, number of times attended hospital and tal amount of time spent attending hospital. At weekends, respondents received a median calls although this varied across specialties from 11.0 for clinical oncology and radiology 3.0 for anaesthetics (table 6). Average values for clinical oncology and radiology are more subject skew due its smaller sample size relative other specialties in table 6. Approximately one-third of respondents (32.8 per cent) on call at the weekend reported not having attend hospital at all. Almost two-thirds (63.3 per cent) reported being called attend between one and six times (figure 4). This is notably higher than the equivalent proportion for Monday Friday on call (47.4 per cent). Collectively, consultants were required attend hospital when on call on a single occasion, on average, although attending twice was more representative for surgical specialties and clinical oncology and radiology. The likelihood of being called attend hospital at the weekend at least once was greatest for surgeons (88.0 per cent) and anaesthetists (82.1 per cent) (figure 5). 10

11 As with Monday Friday, anaesthetists recorded the highest number of minutes spent attending hospital when on call at weekends (53 minutes) compared an average 36 minutes for all consultants. Table 6 Frequency of calls, attendance and tal time spent at hospital when on call at the weekend Specialty (n) Medical specialties (n=132) Surgical specialties (n=86) Anaesthetics (n=67) Paediatrics and child health (n=58) Clinical oncology and radiology (n=47) All (n=493) Frequency of calls received (Sat and/or Sun) Frequency of attendance at hospital (Sat and/or Sun) Total time (mins) in attendance (Sat and/or Sun) Mean Median IQR Mean Median IQR Mean Median IQR IQR: Inter-quartile range Figure 4 Distribution for the number of calls requiring attendance at hospital (Saturday and/or Sunday) Number of calls requiring attendance at hospital 11

12 Figure 5 Likelihood of being called and required attend hospital at least once by specialty (Saturday and/or Sunday) Clinical oncology and radiology Paediatrics and child health Medical specialties Anaesthetics Surgical specialties Required attend Not required attend There were no systematic differences in average minutes spent attending hospital when on call by NHS employer. Any differences were relatively small and very likely a function of normal variation and the group sizes (table 7). Table 7 Frequency of calls, attendance and tal time spent at hospital when on call by NHS employer type 2 (Saturday and/or Sunday) Specialty (n) Normal priority NHS Trust (n=299) Frequency of calls received (Sat and/or Sun) Frequency of attendance at hospital (Sat and/or Sun) Total time (mins) in attendance (Sat and/or Sun) Mean Median IQR Mean Median IQR Mean Median IQR High priority NHS Trust (n=193) All (n=493) Note: Respondents separated in two groups according the priority given by their employing trust progression wards seven day services in the NHS England survey. IQR: Inter-quartile range. 12

13 Almost half of respondents (48.1 per cent) that were on call on the Saturday or Sunday in their most recent full working week did not have their sleep interrupted. However, one-third of respondents (33.6 per cent) were required break their sleep pattern ( attend hospital) and approaching one-fifth (18.3 per cent) reported their sleep had been interrupted on both nights at the weekend. In common with working on call during Monday Friday, there was no difference in rate of sleep disturbance by respondents NHS employer (figure 6). Figure 6 Frequency of sleep disturbance when on call at the weekend (Saturday and/or Sunday) None One night Two nights Compensary rest All respondents were asked if they had access compensary rest following a night spent on call when their sleep has been disturbed. Seven in 10 of all respondents (71.1 per cent) reported they never had access compensary rest while a further one in 10 (10.2 per cent) replied that such rest was rare. Just one in 10 respondents (10.5 per cent) reported that they always or most of the time had access compensary rest. There were no differences according respondents employer (figure 7). 13

14 Figure 7 Access compensary rest following a night spent on call when sleep has been disturbed Never Rarely Ocassionally Most of the time Always NHS Employer core hours of work The survey asked respondents what, the best of their knowledge, was considered be core hours at their NHS employer. The basis for these questions was examine any potential differences in core hospital hours that might be associated with whether the employer was currently giving seven day services a high or normal priority. Figures 8 and 9 suggest a slight difference in when respondents believed core hours began and ended, according NHS employer. Figure 8 shows there is a slight difference in the start time of core hours where respondents in high priority trusts were slightly more likely report core hours beginning at, or before, hours (high priority: 58.9 per cent; normal priority: 44.8 per cent). Figure 9 shows respondents from high priority trusts were also slightly more likely report core hours as ending at hours or later (high: 45.7 per cent; normal: 36.7 per cent). Taken gether, the responses offer tentative evidence of a trend for core hours in high priority employers start earlier and finish later on a typical working day. 14

15 Figure 8 To the nearest half hour, at what time do core hours begin at your main NHS employer? (by normal or high priority NHS employer status) Normal priority Hours (am) High priority Figure 9 To the nearest half hour, at what time do core hours end at your main NHS employer? (by normal or high priority NHS employer status) Hours (pm) Normal priority High priority 15

16 Planned consultant presence in hospitals Weekdays Respondents were asked record the start and finish times of their planned shifts d between Monday and Sunday of their most recent full working week. Figure 10 shows the tal distribution of start and finish times for 764 consultants during an entire 24 hour period on a Wednesday. Wednesday was chosen as a representative example of planned consultant presence at hospital on a weekday. e The vast majority of consultants began their planned shift between and hrs in the morning (blue columns) and finished between and 20 hrs (green columns). Only approximately 1 per cent of consultants reported starting a planned shift at work outside of hrs. When start and finish times are combined, no more than 5 per cent of consultants were present at work outside of hrs. After analysing working patterns for any effect of NHS employer, there were no systematic differences in the start and finish times reported by consultants. Figure 10 The 24-hour distribution of start and finish times for planned consultant shifts on a weekday (n=764) 3 3 Start time Finish time Before 7am or later Note: Figure 10 includes all respondents the survey with complete data for start and finish times. Both full and part time workers are included. d e Planned time was defined as hours of work explicitly agreed in a consultant job plan. Wednesday was chosen as a representative example of planned consultant presence at hospital on a weekday in preference days at the beginning and end of the week which could be more impacted by the proximity weekend shift patterns. 16

17 Weekends The majority of consultants working planned shifts on Saturday reported starting their shift between and 10 hrs in the morning. Finishing times for shifts, and therefore presence at work, was comparatively evenly spread throughout the remainder of Saturday and until midnight. By comparison data for weekday planned presence, the distribution of start and finish times on Saturday lack granularity, due sample size. Figure 11 The 24-hour distribution of start and finish times for planned consultant shifts on Saturday (n=101) 3 3 Start time Finish time Before 7am or later The overall distribution of start and finish times of planned consultant shifts on Sunday is similar in resemblance Saturday working. The vast majority of consultants began their planned shift between and 10 hrs in the morning with finish times relatively evenly spread through the rest of Sunday. The same caveats concerning sample size for consultants working on Saturday also apply Sunday. There were no systematic differences in start and finish times of consultants working at weekends according their NHS employer. 17

18 Figure 12 The 24-hour distribution of start and finish times for planned consultant shifts on Sunday (n=90) 4 3 Start time Finish time Before 7am or later 18

19 Appendix Demography Country of work Respondents from Northern Ireland were oversampled and are considerably over represented in the survey in comparison with respondents from England. If the workforce consisted of consultants in England and Northern Ireland only, consultants in Northern Ireland would nominally constitute 3.7 per cent 2 rather than 17.6 per cent as in this survey (figure A1). Figure A1 Respondent s country of work 146, 17.6% 682, 82.4% England Northern Ireland Gender More than six in 10 respondents (61.8 per cent) the survey were male. Female respondents (37.4 per cent) were slightly over represented in the survey when compared with the current consultant workforce (33.2 per cent) 2 (table A1). 19

20 Table A1 Respondents gender Frequency Male Female Prefer not say Total * No reply 19 *Total does not add 100 per cent due decimal rounding. Age The mean age of respondents the survey was 48.5 years (median: 48 years; lower quartile: 42 years, upper quartile: 54 years) (figure A2). This is in broad agreement with the age profile of respondents the 2013 consultant survey and the wider consultant workforce. 2 Figure A2 Age distribution of respondents Age (years) Age when first appointed as a consultant The mean age of respondents at their first consultant appointment was 36.6 years (median: 36 years; lower quartile: 34 years, upper quartile: 38 years) (figure A3). This is in close agreement with the 2013 BMA consultant survey which recorded a mean age at first appointment as 37.0 years. 20

21 Figure A3 Age distribution of first consultant appointment Age (years) Working status More than eight in 10 respondents the survey were in full time work (table A2). Table A2 Current working status Frequency Working full time Working part time Working as a locum On a career break On maternity leave Retired Total Note: Respondents that were on a career break, maternity leave or retired were removed from main survey questions. Specialty Assessing the representativeness of the response across hospital specialties is problematic due variation in the method of data collection among professional medical bodies and the NHS. In the current study the General Medical Council (GMC) Definitive List of Approved Specialties and Sub- Specialties was used. 2 There were relatively small differences between 2013 and 2014 surveys. 21

22 Table A3 Main clinical specialty (including comparison with 2013 consultant survey) Frequency (2014) (2013) Anaesthetics Clinical oncology and radiology Emergency medicine Medical specialties Obstetrics and gynaecology Occupational medicine Ophthalmology Paediatrics and child health Pathology Psychiatry Public health medicine Surgical specialties Other Total No reply 1 Table A4 List of NHS Employers in England identified as giving seven day services high priority 2 NHS Employer Whittingn Hospital NHS Trust King s College Hospital NHS Foundation Trust Guy s and St Thomas NHS Foundation Trust St George s Healthcare NHS Trust Dartford and Gravesham NHS Trust Frimley Park Hospital NHS Foundation Trust Hampshire Hospitals NHS Foundation Trust Kettering General Hospital NHS Foundation Trust South Warwickshire NHS Foundation Trust Buckinghamshire Healthcare NHS Trust City Hospitals Sunderland NHS Foundation Trust Colchester Hospital University NHS Foundation Trust Ipswich Hospital NHS Trust Rotherham NHS Foundation Trust Royal Berkshire NHS Foundation Trust University Hospital of South Manchester NHS Foundation Trust Cambridge University Hospitals NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust 22 s

23 References 1 British Medical Association. BMA consultant survey London NHS England. NHS Services, Seven Days a Week Survey of acute hospitals s 23

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