Designing safer rotas for junior doctors in the 48-hour week

Transcription

1 Desgnng safer rotas for junor doctors n the 48-hour week Prepared on behalf of a Multdscplnary Workng Group by Ncholas Horrocks MSc and Roy Pounder MD, DSc, FRCP September 2006

2 Acknowledgements Ths gude was prepared on behalf of a short-term Workng Group that met at the Royal College of Physcans, London, on 4 November For members of the Workng Group, see Appendx 2. The gude was approved by the Councl of the Royal College of Physcans on 18 May Fnancal support for the Workshop and for NH was provded by NHS Natonal Workforce Projects. To access more of ther materals supportng the European Workng Tme Drectve, and the wder ssues around workforce plannng and development, vst Msson statement The Royal College of Physcans plays a leadng role n the delvery of hgh qualty patent care by settng standards of medcal practce and promotng clncal excellence. We provde physcans n the Unted Kngdom and overseas wth educaton, tranng and support throughout ther careers. As an ndependent body representng over 20,000 Fellows and Members worldwde, we advse and work wth government, the publc, patents and other professons to mprove health and health care. Ctaton for ths document Royal College of Physcans. Desgnng safer rotas for junor doctors n the 48-hour week. Prepared on behalf of a multdscplnary workng group by Horrocks N and Pounder R. London: Royal College of Physcans, ROYAL COLLEGE OF PHYSICIANS OF LONDON 11 St Andrews Place, London NW1 4LE Regstered Charty No ISBN Copyrght 2006 Royal College of Physcans of London Revew date: 2009 Copyrght All rghts reserved. No part of ths publcaton may be reproduced n any form (ncludng photocopyng or storng t n any medum by electronc means and whether or not transently or ncdentally to some other use of ths publcaton) wthout the wrtten permsson of the copyrght owner. Applcatons for the copyrght owner s wrtten permsson to reproduce any part of ths publcaton should be addressed to the publsher. Typeset by Dan-Set Graphcs, Telford, Shropshre Prnted n Great Brtan by Sarum ColourVew Group, Salsbury, Wltshre

3 Contents Executve summary v 1 Introducton 1 2 Problems wth nght work 2 Why s there a problem now? 2 What are the dffcultes wth workng nght shfts? 3 Nght shfts and safety 3 Gettng home after a nght shft 3 The rules for full shft workng by junor doctors 5 3 Desgnng rotas 7 How many doctors are needed to form a good rota? 7 1 The seven-nghts-n successon rota 8 2 The four-and-three rota 9 3 The two-two-and-three rota 10 4 The one-nght-at-a-tme weekday rota 11 5The three nne-hour shfts rota 12 6 Three nne-hour weekday shfts, wth 12.5-hour weekend shfts 14 4 Practcal ssues 15 Contnuty of care and team workng 15 How should gaps n a medcal team be flled? 16 What about flexble tranees? 16 How many doctors are needed at nght to cover an acute servce? 16 What s the deal rota for 2009? 17 Appendx 1 Practcal tps for desgnng rotas 19 Appendx 2 Members of the Workng Group 21 References 22

4 Executve summary Followng the mplementaton of the European Workng Tme Drectve Regulatons, the majorty of junor doctors n the UK now work full shfts at nght. A Royal College of Physcans 50-member workng group was establshed to develop both practcal advce for those junor doctors workng nght shfts, and a gude to help those desgnng rotas for junor doctors. The gude, set out n ths document, dscusses the rsks assocated wth shft work at nght and the safety and sutablty of possble rotas, n antcpaton of the 48-hour week n Rotas nvolvng seven consecutve 13-hour nght shfts may ncrease rsks to patents and staff, and are best avoded. The number of nght shfts worked n successon should be lmted to a maxmum of four, and the length of each nght shft should be reduced whenever possble. A cell of 10 junor doctors s necessary for any post that provdes 24-hour cover, plus specalty work and tranng durng weekdays. The gude encourages the testng of three nne-hour shfts to cover the 24 hours to acheve mproved health, safety, teachng and supervson, and effcency. Usng ths evdence-based approach, hosptals should be able to mplement optmal 48-hour rotas by The gude does not suggest rotas for those junor doctors who are non-resdent on call, and they reman at consderable rsk of excess fatgue. It s hoped that the gude, whch should be read n conjuncton wth a prevous report, Workng the nght shft: preparaton, survval and recovery a gude for junor doctors, 1 wll make the challenge of nght shft work not only easer to tolerate, but also safer for both hosptal patents and ther doctors. v

5 1 Introducton Healthcare s a 24-hour process, and many hosptals need doctors to be avalable to provde professonal care round-the-clock. However, workng at nght s dfferent from workng n the day, nvolvng addtonal pressures and rsks. Mnmsng these rsks s an essental part of makng nght work both safe and acceptable to the doctors who must be on duty. One way to do ths s for doctors workng such shfts to be made aware of the rsks nvolved. Preparaton for workng a nght shft s a key part of ths and the booklet, Workng the nght shft: preparaton, survval and recovery A gude for junor doctors, 1 provdes gudance on ths. However, wth even the best preparaton, workng at nght can stll have consequences for the safety of both patents and doctors, as t ncreases the lkelhood of makng poor decsons or even mstakes. Rotas that do not consder the sleep requrements and safety of those who work them wll only ncrease the rsk. The am of ths gude s to hghlght why certan rotas are more approprate than others, and to provde suggestons on how to desgn safe and acceptable work schedules for doctors who must work at nght. It has been wrtten n antcpaton of the 48-hour workng week beng undertaken by tranee doctors n 2009, but the advce can be appled to relevant rotas now. Bref examples are ncluded to demonstrate partcular ponts and to provde a bass upon whch other rotas can be drawn up. The gude s not only for hosptal admnstrators who desgn rotas for medcal staff but also for junor doctors. It s mperatve that doctors workng such rotas get nvolved n ther plannng at an early stage not least because the optmal solutons for every rota, team and hosptal wll be dfferent. 1

6 2 Problems wth nght work Why s there a problem now? Treatng sck patents at nght s nothng new, and some doctors have always been asked to work at nght. So why s there a problem now? In 2004 the Workng Tme Regulatons (the enactment n UK law of the European Workng Tme Drectve) were appled to junor doctors. In combnaton wth the New Deal, ths legslaton has reduced the average number of hours that junor doctors can work. Whle there reman 168 hours n each week, the Workng Tme Regulatons state that by 2009 junor doctors can only be expected to work on average a maxmum of 48 of these hours each week. Ths s a reducton of approxmately 15% from the current maxmum of 56 hours of weekly work allowed under New Deal rules. A consequence of these postve steps has been that patterns of workng for junor doctors have also changed. The tradtonal on-call soluton to provdng care n the hosptal at nght s no longer workable for the majorty of specaltes and most junor doctors n the UK now work nght shfts that s, report for work n the evenng after a day off, work overnght, and then go off duty n the mornng. Although ths change s not n tself necessarly a bad thng, there has often been poor consderaton of the safety and sleep requrements of junor doctors when desgnng new rotas for nght shft work. Ths has resulted n many rotas that are not deal from a health and safety pont of vew. Should junor doctors be treated dfferently to other NHS nght workers? There a number of mportant dfferences: Frstly, junor doctors have been swtched from on-call to shft work n the last few years, and the frst roster patterns that were mplemented were often unsutable. Secondly, the junors are subject to the rules of the New Deal wth a 48-hour average week for most n 2009, whlst other employees are subject to Agenda for Change wth a 37.5-hour week. Thrdly, junors are stll n tranng and must have a substantal proporton of ther workng tme dedcated to learnng. Fnally, most junor doctors are rotated from job to job, and many do not lve close to ther allocated hosptal. Whlst some other NHS workers could also beneft from the type of rota suggested n ths gude, almost all would beneft from the advce found n Workng the nght shft: preparaton, survval and recovery A gude for junor doctors. 1 2

7 2 Problems wth nght work What are the dffcultes wth workng nght shfts? Workng at nght s harder than workng durng the day, because ths s the tme when the human body s programmed to be asleep. It also results n loss of sleep and ncreased fatgue, whch drectly mpacts on performance. Workng at nght nvolves tryng to functon when one s alertness, vglance and cogntve reasonng are all at ther lowest, makng t s easer to make mstakes wthout notcng. 2 Tred junor doctors n the USA and Denmark dd exactly ths, and were shown to lose concentraton more often and make more clncal errors compared to when they were able to get more sleep. 3 7 Of partcular relevance to junor doctors n tranng, exhauston also mpars recent learnng and can decrease ther ablty to make correct dagnoses and perform techncal procedures. 4,8,9 Importantly, because workng a nght shft nvolves tryng to sleep n the day, the lack of sleep can quckly become excessve. Sleepng durng the day s much harder than sleepng at nght, because t s not what humans are desgned to do. Brght sunlght, temperature, and nose can all keep nght workers awake durng the day, but perhaps most mportantly, the body s nternal clock, whch regulates sleep wake patterns, acts to mantan alertness and wakefulness. Ths means that daytme sleep s not of such good qualty or duraton as sleep at nght; 10 shft workers who work several consecutve nght shfts can become progressvely more tred over the course of ther duty. Inevtably ths can then lead to further reductons n performance and an ncreased lkelhood of accdents or mstakes. Nght shfts and safety Whle workng at nght does contrbute to an ncreased rsk of makng errors, ths s not the only factor to consder. Evdence collected from a range of ndustres where shft work s common shows that the length of ndvdual shfts and the number of shfts worked n successon are also very mportant. 11,12 The more shfts that are worked consecutvely, the greater the relatve rsk compared to the frst shft worked. Lkewse for the length of each shft the longer each shft lastng more than eght hours, the greater the chance of an accdent (Fg 1). Interestngly, f two otherwse dentcal shfts n terms of length and number of prevously worked shfts are compared, the rsk of an accdent s always greater on the nght shft than durng the day (Fg 2). Shft length and the number of consecutve shfts must always be consdered when desgnng new rotas. Furthermore, because of the ncreased rsk wth workng at nght, t s essental to remember that what s an acceptable rota for workng durng the day may not be sensble when plannng nght shfts. Gettng home after a nght shft Desgnng safe rotas does not just nvolve consderng the doctor at work. After the shft, doctors must also be able to travel home safely, and often ths wll mean drvng. Ths s not a problem for those lvng n hosptal accommodaton or nearby, or f publc transport s avalable, but many specalst regstrars (SpRs) are on rotatons and do not lve close to where they work. Data collected from medcal SpRs n January 2006 ndcate that for 46% the daly commute s 30 to 60 mnutes, each way and t was greater than one hour for 16%. 13 Just as wth performance on duty, drvng ablty s strongly affected by fatgue and lack of sleep. Whle ths s less of a problem f doctors work two to three shorter nght shfts at a tme, 3

8 Desgnng safer rotas for junor doctors Estmated rsk Shft duraton (hours) Fg 1. The estmated rsk of accdents n shft workers, related to length of shft. 11, 12 An eghthour shft has been set to have an estmated rsk of 1.0, wth all other shfts relatve to ths Days Nghts Relatve rsk st 2nd 3rd 4th Successve shfts Fg 2. The estmated rsk of accdents n shft workers, related to the number of successve shfts and whether they are day or nght shfts. 11,12 The frst day shft has been set to have a relatve rsk of 1.0 and all other shfts are relatve to ths. 4

9 2 Problems wth nght work approprate nappng and preparaton are nonetheless necessary. Drvng whle tred becomes an ncreasng potental hazard as shft length and the number of nghts worked n successon rse, partcularly f the recommendatons n Workng the nght shft: preparaton, survval and recovery A gude for junor doctors 1 are not followed. Sleepy drvers have been calculated to cause 10% of all UK road crashes, wth ths percentage rsng for accdents on monotonous motorways and smlar trunk roads. 14,15 Such crashes are often more serous than non-sleep-related accdents, snce the vctm may mpact at speed, havng made no attempt to brake before crashng. Nght workers travellng home at the end of a shft have been dentfed n nternatonal studes as beng partcularly at rsk of sleep-related vehcle accdents To quantfy ths rsk, the performance mparment assocated wth fatgue has been compared to that produced by alcohol; hours wthout sleep was shown to reduce psychomotor performance to the level of someone wth a blood alcohol concentraton of 0.10% Ths s greater than the current maxmum level for legal drvng n the UK (0.08%). However, a doctor who has worked just one nght and was wthout rest durng the day leadng nto the shft could easly acheve a perod of sleep deprvaton of ths length. Ths s why doctors reportng for nght duty must be fully rested. If junor doctors contnue to be rostered to work long sequences of lengthy nght shfts, t may be more approprate for hosptals to consder provdng transport for those who have to travel greater dstances to and from work. Although ths may at frst seem prohbtvely expensve, such costs should be consdered n lght of the alternatve optons whch may nclude the provson of temporary local accommodaton, or ndeed dong nothng. Postgraduate medcal tranng often requres that some junor doctors rotate to posts dstant from ther homes, and t s essental that hosptal managers are fully aware of ther duty of care as employers. As such, they should make sure that doctors lvng at a dstance from ther workplace take full advantage of the relocaton allowances payable on rotaton to avod the need for extended travel. 26 An deal rota wll attempt to mnmse fatgue and rsk (Table 7). The rules for full shft workng by junor doctors The Workng Tme Regulatons are Health and Safety law and the New Deal sets out condtons of servce relatng to pay, but together they mpose strct rules that affect how rotas mght be desgned for junor doctors n tranng. From 1 August 2009, the two standards wll underpn the followng rules: The maxmum average number of hours on duty s 48 per week (averaged over a 26- week perod). The mnmum break between shfts must be 11 hours. The maxmum contnuous perod of duty s 13 hours - that s, no shft can be scheduled to last longer than 13 hours. The maxmum number of consecutve days of duty s 12, wth a mnmum break of 48 hours n each two-week perod, unless compensatory rest s gven. There must be 62- and 48-hour breaks every 28 days. 5

10 Desgnng safer rotas for junor doctors There must be 35 hours of contnuous rest n 7 days or 59 contnuous hours rest n 14 days. There must be at least one 30-mnute contnuous break after approxmately four hours on duty. A more detaled breakdown and comparson of the New Deal and Workng Tme Regulatons, and how they must be appled together, can be found on the healthcareworkforce.org.uk webste. 27 Taken together, these standards mean that only certan rotas are permssble. 6

11 3 Desgnng rotas How many doctors are needed to form a good rota? To ad smplcty of presentaton, the sx example rotas gven n ths gude all nvolve a group of junor doctors n tranng of equvalent experence (called a cell ) who can form a rota to work n a partcular post that requres 24-hour on-ste cover. The remander of ther tme workng from Monday to Frday s spent durng the day, for example, completng essental clncal work on the ward, n clncs or performng procedures, or recevng tranng. The daytme shfts are fxed n average length but are flexble, such that they can start early or fnsh late. Each rota only covers one doctor on call at a tme, wth some handover; f three doctors are needed on call, each wll be part of a dfferent rota, n ths case nvolvng three cells of 10, or 30 doctors. There are 10 doctors n the cell; t s suggested that any fewer makes the rota unacceptable because, dependng on the specalty and daytme commtment, the servce work wll domnate nonclncal work n a way that would be unacceptable n a tranng post (Fg 3). 28 Constructng a rota becomes progressvely easer f there are more than 10 doctors n the cell. If the post nvolves perods of duty on call as well as workng as part of a specalty frm for example, SpRs n respratory medcne who also cover acute medcal take then a cell wth fewer than 10 doctors of equvalent experence wll be unacceptable. Postgraduate deans and the Postgraduate Medcal Educaton Tranng Board must revew whether such posts can be consdered sutable for tranng junor doctors. A cell of fewer than 10 doctors may be acceptable for some posts that nvolve only a sngle type of duty for example, senor house offcers (SHOs) workng exclusvely n the accdent & emergency department (A&E), or others dedcated to a medcal admssons unt. Fgure 3 llustrates the dstrbuton of dutes n a 56-hour week related to the number of doctors n the cell. In 2009, the 48-hour lmt wll make no dfference to the work needed on the shfts and all the pressure wll be on daytme non-shft actvty that s, ward work, clncs, procedures and tranng. 60 SpR rotas nvolvng full shfts 50 Dedcated hours per SpR No. of SpRs n a cell Ward work, clncs, procedures, tranng Daytme and weekend admssons shfts Nghttme shfts Fg 3. The case for a cell of ten to provde 24-hour shft cover by junor doctors who are workng a 56-hour week. 28 In a 48-hour week all the savngs wll have to be made n the daytme non-shft work. 7

12 Desgnng safer rotas for junor doctors (1) The seven-nghts-n-successon rota Ths rota nvolves workng seven 12.5-hour nght shfts n successon (Table 1), and s essentally the worst possble rota that can be devsed n terms of safety and sleep requrements. Over the course of the week a doctor workng ths rota s expected to be on duty for a total of 87.5 hours ( hours) but only receves 80.5 hours of breaks wthn that same perod. Such a schedule would be dauntng n the daytme, but coupled wth the nevtable sleep deprvaton that results from repeated nght work, t s clearly wrong. Table 7 demonstrates that ths rota results n the worst fatgue and rsk scores, as estmated by the Health and Safety Executve assessment tool. Ths means that, of all the rotas presented n ths gude, ths rota s assocated wth the greatest rsk of accdent and the hghest levels of fatgue (Table 7). Even f a seven-nghts-n-successon rota s popular wth some junor doctors, the health and safety mplcatons are such that an employer should mpose a change to a safer rota. Table 1. A seven-nghts-n-successon rota. Ths example s both New Deal- and EWTD-complant, and t provdes an average 48-hour week. However, we do not recommend ts use n the NHS. (Ten doctors rotatng n one cell; Daytme 8h means that the junor can work for 8 hours on hs or her frm, at any tme n the day or evenng.) Mon Tues Wed Thur Fr Sat Sun 1 21:00-09:30 21:00-09:30 21:00-09:30 21:00-09:30 21:00-09:30 21:00-09:30 21:00-09:30 2 Zero hours Zero hours Zero hours Zero hours Zero hours 3 09:00-21:30 Daytme 8h Daytme 8h Daytme 8h Daytme 8h 4 Daytme 8h 09:00-21:30 Daytme 8h Daytme 8h Daytme 8h 5 Daytme 8h Daytme 8h 09:00-21:30 Daytme 8h Daytme 8h 6 Daytme 8h Daytme 8h Daytme 8h 09:00-21:30 Daytme 8h 7 Daytme 8h Daytme 8h Daytme 8h Daytme 8h 09:00-21:30 09:00-21:30 09:00-21:30 8 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 9 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 10 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 8

13 3 Desgnng rotas (2) The four-and-three rota A more acceptable alternatve to the seven-nghts-n-successon rota s one where the seven nght shfts are broken up, typcally nto blocks of four and three (Table 2). Ths separates the week nto week nghts and weekend nghts, wth Frday nght ncluded as a weekend nght, because anyone workng over Frday nght wll end ther shft on a Saturday mornng, whch under New Deal rules would count as weekend workng. The groupng together of Frday, Saturday and Sunday works well as t mproves the effcency of a rota. It also reduces the number of doctors wth dsrupted weekends. In addton, because one par of doctors n ths cell s coverng the days and the nghts over the weekend, contnuty of care and handover are mproved. The four-and-three rota has been adopted n most New Zealand hosptals, where junor doctors have worked shorter hours for the last ten years; these doctors work a short nght and most of ther hosptals have only a small number of tranees. Many Brtsh hosptals have already swtched to ths pattern. Although the four-and-three soluton nvolves fewer consecutve shfts than the seven-nghtsn-successon rota, a doctor wll stll be workng overnght for up to 50 hours n one block. Ths remans ntensve shft work, and requres adequate preparaton and recovery. Suffcent days off both before and after the sequence of nght shfts should therefore be ncluded n the rota. Doctors should be encouraged to use ths tme, especally beforehand, to get themselves refreshed and ready to start workng at nght. A bg dsadvantage of ths rota, whch wll be dscussed later, s that only two doctors cover the weekend and they only have 30 mnutes for handover. Table 2. A possble four-and-three rota. Ths example s both New Deal- and EWTD-complant, and t provdes an average 48-hour week. (Ten doctors rotatng n one cell; untl 2009, some doctors workng the flexble Daytme 8h shfts could work up to a 13-hour day, to provde extra cover at ether end of the day.) Mon Tues Wed Thur Fr Sat Sun 1 21:00-09:30 21:00-09:30 21:00-09:30 21:00-09:30 Zero hours 2 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 3 Daytme 8h Daytme 8h Daytme 8h Zero hours 09:00-21:30 09:00-21:30 09:00-21:30 4 Daytme 8h Daytme 8h Daytme 8h 09:00-21:30 Daytme 8h 5 Daytme 8h Daytme 8h 09:00-21:30 Daytme 8h Daytme 8h 6 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 7 09:00-21:30 09:00-21:30 Zero hours Zero hours 21:00-09:30 21:00-09:30 21:00-09:30 8 Zero hours Zero hours Daytme 8h Daytme 8h Daytme 8h 9 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 10 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 9

14 Desgnng safer rotas for junor doctors (3) The two-two-and-three rota Ths s smply a varaton on the four-and-three pattern, but t breaks up the four nghts nto two blocks of two (Table 3), thus reducng the rsk of exhauston and mprovng safety. Interestngly, despte the fact that two doctors are removed from daytme dutes for part of the week, the number of unbroken weeks avalable for daytme clncs remans the same as wth the four-and-three rota. For a team of 10 doctors there wll be sx weeks n the ten-week cycle of the rota where each doctor s theoretcally present between at least 09:00h and 17:00h from Monday to Frday wthout a break. Ths s an mportant consderaton for the tranng of junor doctors and for mantanng regular contact wth consultants, as well as for plannng leave. Havng two doctors coverng the week nghts ncreases the number of handovers that must occur between dfferent doctors from fve wth a four-and-three rota, to seven. However, snce the nght doctor should be fresher than f they had worked more consecutve nghts, t s unclear what potental consequences an addtonal two new handovers mght have for contnuty of care. Table 3. A two-two-and-three rota. Ths example s both New Deal- and EWTD-complant, and t provdes an average 48-hour week. (Ten doctors rotatng n one cell; untl 2009, some doctors workng the flexble Daytme 8h shfts could work up to a 13-hour day, to provde extra cover at the end of the day.) Mon Tues Wed Thur Fr Sat Sun 1 21:00-09:30 21:00-09:30 Zero hours Zero hours Daytme 8h 2 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 3 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 4 Daytme 8h Daytme 8h Daytme 8h Daytme 8h 21:00-09:30 21:00-09:30 21:00-09:30 5 Zero hours Zero hours Zero hours 09:00-21:30 Daytme 8h 6 Daytme 8h Daytme 8h 09:00-21:30 Daytme 8h Daytme 8h 7 Daytme 8h 09:00-21:30 Daytme 8h Daytme 8h Daytme 8h 8 09:00-21:30 Daytme 8h 21:00-09:30 21:00-09:30 Zero hours 9 Daytme 8h Daytme 8h Daytme 8h Daytme 8h 09:00-21:30 09:00-21:30 09:00-21:30 10 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 10

15 3 Desgnng rotas (4) The one-nght-at-a-tme weekday rota In terms of doctor exhauston and patent safety, workng only one nght at a tme would undoubtedly seem a good soluton for provson of cover n the hosptal over the nght. Because each doctor only works a sngle nght shft, hs or her recovery perod wll be shorter. In addton, durng the nght shft doctors should be less fatgued and would not suffer from the accumulaton of tredness resultng from workng several consecutve nght shfts. The dsadvantage of workng every nght n ths way would be that three dfferent doctors would cover one post at nght over a weekend, and hence dsrupt three weekends for nght work n each cycle of the rota. Complance wth the New Deal s also dffcult, but a compromse rota can be acheved by plannng three successve nght shfts over the weekend (Frday to Sunday), but four sngle nght shfts durng the week (Table 4). Another pont to consder s that the number of handovers between dfferent doctors s ncreased to nne, and n ths example there are four unbroken weeks of daytme duty wthn the 10-week cycle of the rota. Agan, only two doctors cover each weekend, wth lttle tme for handover. Table 4. A one-nght-at-a-tme weekday rota. Ths example s both New Deal- and EWTD-complant, and t provdes an average 48-hour week. (Ten doctors rotatng n one cell; untl 2009, some doctors workng the flexble Daytme 8h shfts could work a 13-hour day, to provde extra cover at ether end of the day.) Mon Tues Wed Thur Fr Sat Sun 1 Daytme 8h Daytme 8h Daytme 8h Daytme 8h 21:00-09:30 21:00-09:30 21:00-09:30 2 Zero hours Zero hours Daytme 8h Daytme 8h Daytme 8h 3 Daytme 8h 21:00-09:30 Zero hours 09:00-21:30 Daytme 8h 4 Daytme 8h Daytme 8h 21:00-09:30 Zero hours Daytme 8h 5 Daytme 8h Daytme 8h Daytme 8h Daytme 8h 09:00-21:30 09:00-21:30 09:00-21:30 6 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 7 21:00-09:30 Zero hours 09:00-21:30 Daytme 8h Daytme 8h 8 09:00-21:30 Daytme 8h Daytme 8h 21:00-09:30 Zero hours 9 Daytme 8h 09:00-21:30 Daytme 8h Daytme 8h Daytme 8h 10 Daytme 8h Daytme 8h Daytme 8h Daytme 8h Daytme 8h 11

16 Desgnng safer rotas for junor doctors (5) The three nne-hour shfts rota What s the optmum length of each nght shft for a junor doctor? The relatve rsk assocated wth one partcular schedule compared to another s dependent on both the number of shfts worked n successon, and the length of each shft. Wth the maxmum shft length beng 13 hours, and the mnmum break between shfts set at 11 hours, t appears very attractve to desgn rotas wth 13-hour shfts. Ths allows two dfferent doctors to cover one post for each 24-hour perod and also provdes an hour at ether end for reasonable handovers. However, doctors carryng out work n the late afternoon and evenng are dong so when exhausted, towards the end of the daytme 13-hour shft. In addton, f a junor doctor over-runs a 13-hour shft by one hour, not only wll a penalty Band Three payment be trggered under the New Deal, but the Workng Tme Regulatons wll be breached, requrng mmedate compensatory rest. In a busy hosptal, ths over-runnng wll occur frequently f there are only mnutes for handover. No shft should be scheduled to be close to the 13-hour lmt. If the nght doctor works less than a 12-hour shft, then there wll have to be two doctors workng longer daytme shfts. Three nne-hour shfts wll provde 24-hour cover (Table 5), and ths could be acheved wth an early shft from 07:00 to 16:00h, a late shft from 15:00 to 00:00h, and a nght shft from 23:00 to 08:00h. The standard day shft could run flexbly from, say, 09:00 to 18:00h. Workng untl mdnght does have safety ssues, but of the same order as any shft endng n darkness between 20:00 and 23:00h. Even wth 10 doctors n a cell, t s mpossble to devse a rota, wthn the rules of the New Deal, wth only one nne-hour nght shft at a tme. Hence Table 5 rosters two nghts at a tme n the week, and three at the weekend. Table 5. A rota wth three nne-hour shfts per 24 hours. Ths example s both New Deal- and EWTD-complant, and t provdes an average 48-hour week. (Ten doctors rotatng n one cell; untl 2009, some doctors workng the flexble Daytme 9h shfts could work a 13-hour day, to provde extra cover at ether end of the day.) Mon Tues Wed Thur Fr Sat Sun 1 23:00-08:00 23:00-08:00 Zero hours Zero hours Daytme 9h 2 Daytme 9h Daytme 9h Daytme 9h 07:00-16:00 07:00-16: :00-00:00 15:00-00:00 23:00-08:00 23:00-08:00 Zero hours 4 Daytme 9h Daytme 9h Daytme 9h Daytme 9h Daytme 9h 07:00-16:00 07:00-16:00 5 Daytme 9h Daytme 9h Daytme 9h Daytme 9h Daytme 9h 6 Daytme 9h Daytme 9h Daytme 9h Daytme 9h Daytme 9h 7 Daytme 9h Daytme 9h 15:00-00:00 15:00-00:00 23:00-08:00 23:00-08:00 23:00-08:00 8 Zero hours Zero hours Daytme 9h Daytme 9h Daytme 9h 9 Daytme 9h Daytme 9h Daytme 9h Daytme 9h Daytme 9h 10 07:00-16:00 07:00-16:00 07:00-16:00 Zero hours 15:00-00:00 15:00-00:00 15:00-00:00 12

17 3 Desgnng rotas Three nne-hour shfts per 24 hours have a number of advantages over all the other shfts proposed n ths gude: A shorter shft should lead to less doctor exhauston, wth ts assocated errors and loss of clncal precson, also makng workng practces more effcent. The change from two 13-hour shfts n 24 hours to three nne-hour shfts also alters the proporton of hours on the nght shft from 50% to only 33% of the tme on duty. Ths also provdes fresher doctors n the late afternoon and early evenng, at the peak of demand for most acute specaltes. 29 Ths rota ntroduces a regularty to junors work that s, on average each week s made up of fve nne-hour shfts. Workng alongsde the two nne-hour day shfts may be more acceptable for consultants, wth ncreased opportuntes for teachng and supervson. Nne-hour shfts are partcularly suted to those posts wth almost contnuous ntensve work for example, junors n A&E, the junor doctors durng an acute medcal take, tranees workng n an ntensve treatment unt/crtcal care unt or a neonatal unt. They are sutable for surgcal specaltes, where the 23:00 to 08:00h shft could be covered by less experenced staff, wth expert assstance on call at home for rare surgcal nterventons. A nne-hour shft s extremely unlkely to over-run to more than 13 hours; hence the Band Three penalty payment s not lkely to be trggered, nor a breach of the Workng Tme Regulatons. On Saturday and Sunday the daytme shfts could be lengthened by a few hours, to provde extra non-acute medcal cover n the afternoon and early evenng (wth compensatory shorter days durng the week). Crucally, a rota of three nne-hour shfts per 24 hours, seven days a week, provdes the lowest levels of estmated fatgue and rsk of all the sx specmen rotas (Table 7). Lnes 5, 6 and 9 n Table 5 can ndvdually (or all) be elmnated to construct 9- to 7-cell rotas. Wth mnor adjustment, all the new rotas are Band 1A under the New Deal; however, less and less tme s allocated to daytme clncal work and tranng, and they become progressvely more unacceptable. Fnally, the three nne-hour duty shfts can be adjusted n length to sut local actvty, as long as the total hours for the three shfts add up to 27 hours. Thus the mornng shft could start at 07:00h and last 10 hours; the second shft could start at 16:00h and fnsh after seven hours at 23:00h; the nght shft could start at 22:00h and fnsh the next mornng 10 hours later at 08:00h. 13

18 Desgnng safer rotas for junor doctors (6) Three nne-hour weekday shfts, wth 12.5-hour weekend shfts An obvous drawback to schedulng nne-hour shfts s the need for three doctors to cover a weekend. A mxed rota, however, wth standard 12.5-hour shfts on Frday, Saturday and Sunday, would overcome ths problem (Table 6). Ths soluton would also mean that at 21:00h on a Frday three doctors would stll be on duty, and at 23:00h two doctors, potentally provdng more opportunty for any left-over jobs to be completed before handng over entrely to the weekend team. Ths compares very favourably to rotas wth only 12.5-hour shfts, where cover on a Frday evenng has dropped to just the nght doctor by only 21:00h (Tables 1 to 4). Ths mmedately places addtonal pressure on ths doctor who can be expected to fnsh off jobs that the daytme team have not completed, as well as coverng any other dutes that are requred throughout the nght. However, the rota demonstrated n Table 6 has the major dsadvantage of the long weekend shfts, wth nsuffcent tme for handover, and the rsk of breachng the 13-hour tme lmt. Table 6. A rota wth three nne-hour shfts on weekdays (Monday to Frday) and 12.5-hour shfts over the weekend (Frday to Sunday). Ths example s both New Deal- and EWTD-complant, and t provdes an average 48-hour week. (Ten doctors rotatng n one cell; untl 2009, some doctors workng the flexble Daytme 9h shfts could work a 13-hour day, to provde extra cover at ether end of the day.) Mon Tues Wed Thur Fr Sat Sun 1 23:00-08:00 23:00-08:00 Zero hours Zero hours 09:00-21:30 09:00-21:30 09:00-21:30 2 Daytme 9h Daytme 9h Daytme 9h Daytme 9h Daytme 9h 3 15:00-00:00 15:00-00:00 23:00-08:00 23:00-08:00 Zero hours 4 Daytme 9h Daytme 9h Daytme 9h 07:00-16:00 07:00-16:00 5 Daytme 9h Daytme 9h Zero hours Daytme 9h 21:00-09:30 21:00-09:30 21:00-09:30 6 Zero hours Zero hours 15:00-00:00 15:00-00:00 15:00-00:00 7 Daytme 9h Daytme 9h Daytme 9h Daytme 9h Daytme 9h 8 07:00-16:00 07:00-16:00 07:00-16:00 Daytme 9h Daytme 9h 9 Daytme 9h Daytme 9h Daytme 9h Daytme 9h Daytme 9h 10 Daytme 9h Daytme 9h Daytme 9h Daytme 9h Daytme 9h 14

19 4 Practcal ssues Contnuty of care and team workng Despte the need for 24-hour care, the Hosptal at Nght project showed that work actvty n acute hosptals s not constant at all tmes, wth a crescendo n the early evenng n many specaltes. Workload falls away to a varable extent after mdnght. 29 The three nne-hour shft schedule would be a better way of dealng wth ths type of workload, but t s essental to remember that contnuty of care and daytme team workng are also mportant. In some cases both may have suffered from neffectve mplementaton of the Workng Tme Regulatons, wth assocated mpacts on patent safety and doctor tranng Therefore, although most of the focus of ths gude has been on coverng the nght, any soluton must also remember the consttuton of the day team. One way to take account of ths s to try to desgn rotas wth each level n a team matched aganst a partner or duplcate, so that at any one tme at least half the team remans ntact. Whenever one member of the par s engaged n nght work, the other should always be free for day dutes. Ths can have the effect of appearng to splt any team n two, snce the two halves wll almost never cross paths, so some leeway to allow both members of a par to have at least one day together may be advsable. It s also mportant to check parallel rotas of each grade of junor wthn each daytme frm, to ensure there s no fluctuaton from feast to famne. If at all possble, the rotas of junor doctors n a frm should be synchronsed and runnng on the same cycle, otherwse ncompatbltes and crses wll recur tme and agan. Ths may be mpossble, however, f the numbers of doctors n each cell, workng at dfferent levels, are dfferent. More advce on mantanng contnuty of care can be found n the Royal College of Physcans Contnuty of care for medcal npatents: standards of good practce 33 and also n Safe handover: safe patents Gudance on clncal handover for clncans and managers 34 wrtten by the BMA Junor Doctors Commttee. Another mportant pont to consder s the level of experence and skll that s avalable to call upon durng a nght shft. Whle overall work actvty drops away after mdnght, ths does not mean that the level of practce or knowledge requred by a doctor also falls after ths tme. Incdents where a more experenced doctor s requred wll stll occur overnght. If there s only one hgher-grade doctor on duty then they are lkely to be ted-up dealng wth ths type of patent. Inevtably, wth no other senor staff avalable the remander of the patents n the hosptal are then left under the care of less qualfed staff. When thnkng about the levels of cover n the hosptal at nght t must not be forgotten that there may well be tmes when not everyone on duty wll be avalable at the same tme, and so the qualty and depth of cover f a key member of the nght team s removed by an emergency should be consdered. Fnally, the successful mplementaton of cross-dscplnary team workng, as developed by Hosptal at Nght, can provde effectve support for junor doctors when workng out of normal hours

20 Desgnng safer rotas for junor doctors How should gaps n a medcal team be flled? Predctable gaps n the make-up of medcal teams wll occur because members work nght shfts wth less predctable absences due to holdays, study leave, sck leave, maternty or paternty leave and professonal leave. It s mportant to consder that, when added together, all the possble reasons for absence mean that the average junor doctor may be away from hs or her day team for nearly half of the year. If rotas are desgned wth doctors pared-up, as descrbed above, ths can make t easer to cope wth absences from the day team caused by members workng at nght. Prospectve cover should also be factored n when desgnng rotas to gve an dea of what addtonal hours of cover n the evenng or at weekends can be provded from wthn the team. Such calculatons provde only an ndcaton and may not be possble n realty. Most trusts do not have enough tranees to provde duplcate medcal cover, so f a doctor s away when rostered for day or nght work, no substtute s avalable. In New Zealand, each junor doctor spends about 20% of a post as a nght relever that s, as a general locum for the hosptal coverng absences due to leave. Thus, f a junor rotates every 10 weeks durng a year, one of the 10-week posts would be as a general locum. In the UK, a trust could adopt such a polcy, but t wll nterfere wth tranng. Alternatvely, a trust could appont a full-tme non-tranng grade junor doctor, who could cover the leave of four to fve junors, and avod the cost and neffcency of prospectve cover or locums. What about flexble tranees? Creatng a workable rota wth full-tme employees s dffcult, and the addton of flexble tranee posts wll usually add asymmetry to a pattern that rotates accordng to a regular cycle. The deal soluton s for several flexble tranees to be responsble for one or more posts n the rota thus the overall rota pattern wll contnue undsturbed, and the shorter workng hours should be accommodated wth some adaptablty between the flexble tranees. One crtcsm of the rota n Table 5 s that the standard workng day for all doctors, even f not on call, s 9 hours whch could make chldcare dffcult. However, t should not be mpossble for those who need to work a shorter day to negotate less hours each routne work day, wth less pay. How many doctors are needed at nght to cover an acute servce? There are obvous pressures (n terms of stress, tranng and economcs) to roster the least number of doctors necessary to cover the nght shft. Furthermore, the optmal rato of staff to patents wll vary from dscplne to dscplne and hosptal to hosptal. A survey of junor medcal staffng n England, carred out between January and March 2006, revealed that the most common staffng pattern for general medcal care at 02:00h was one SpR, and ether two SHOs or one SHO and one Foundaton year These three doctors cover a hosptal admttng an average of 32 medcal patents per 24 hours, and are responsble for 227 medcal npatent beds. Clearly, these doctors wll be very busy, and each must also be allowed a break of at least 30 mnutes duraton after every four hours of work. There s no scope for economsng on ths level of staffng n the future ndeed economes n medcal tme n 16

21 4 Practcal ssues antcpaton of the 48-hour week n 2009 must take place n the daytme rather than by cuttng staff numbers at nght. More effcent use of all hours of daytme and evenng workng, such as would be possble wth weekday nne-hour shfts, s lkely to be the best way to acheve complance n What s the deal rota for 2009? It s beyond the scope of ths gude to proclam an deal rota because local crcumstances and needs wll nevtably have a part to play. Desgnng a rota s always a compromse, and must encompass many varables for example, there are sgnfcant dfferences between how teams of anaesthetsts and other doctors delver clncal care compared wth physcans. All the 10-na-cell rotas shown n ths gude are complant for the New Deal and Workng Tme Regulatons as they wll stand n 2009, and so all could be worked wthn a 48-hour week. Untl that tme t s possble for those doctors, who are presently rostered to work 8- to 10-hour daytme shfts, to work addtonal hours provdng extra cover at ether the begnnng or the end of the day. Ths mght, however, alter the bandng status of the rotas, whch are currently all ether 1A or 1B; all the rotas n ths gude have been checked usng Doctors Rosterng System, North Central London Strategc Health Authorty, London, England; The Fatgue and Rsk Indces are the latest tools prepared for the Health and Safety Executve. 36,37 The Fatgue Index uses an arbtrary scale of 0 100, and values above about are seldom seen n any ndustry. The Fatgue Index estmates the average and maxmum Fatgue Index values to be 23.1 and 44.8, respectvely, for the common 12-hour ndustral shft system namely, DDNN (day-day-nght-nght-off-off-off-off); ths system averages a 42-hour week, and provdes a constant level of mannng, 24/7, usng four teams. The Rsk Index average value has been set at for the DDNN system. Table 7 provdes a summary of all the rotas n ths gude for easy comparson. Assessment of the estmated fatgue and the rsk of accdent for each rota shows that the worst rota s seven 13-hour nghts n successon, and the best s three nne-hour shfts. Usng the same tools, a fve-day week, made up of entrely daytme shfts of h, would yeld values for the Fatgue Index of an average 3.90 and a maxmum of 6.20, and for the Rsk Index an average and a maxmum of The average Rsk Index values for other schedules ndcate whether (and by how much) the rsk vares from that of the DDNN system. Thus workng the 7 13-hour nght rota (Table 1) the average rsk s only 4% hgher than on the DDNN system, reflectng the fact that there s only a sngle span of 7 13-hour nghts per 10-week perod. Perhaps more mportantly, the maxmum rsk on the 7 13-hour nght rota s 1.74 (on the last nght shft), whch represents a 41% ncrease over the maxmum rsk value of 1.23 obtaned on the last (second) nght on the DDNN system. As preparatons for 2009 contnue, trusts may need to alter rotas more than once to meet changng needs and no rota should be consdered fxed n stone. Three years s too long to leave unchanged those rotas nvolvng seven 13-hour nght shfts n successon, but leaves lttle tme for gettng new rotas rght. There s an urgent need for prospectve research, testng one or more of the rotas demonstrated n ths gude, to determne the optmal rota system for mplementaton n

22 Desgnng safer rotas for junor doctors In the meantme, t s our hope that the deas and suggestons provded n ths gude may ease the transton to a 48-hour workng week for junor doctors and, at the same tme, make workng condtons safer and more pleasant for these doctors, preserve medcal tranng, and mantan hgh standards of patent care. Table 7 A summary of the dfferent rotas provded n ths gude, wth assessments of fatgue and rsk. 36,37 Nne-hour weekday shfts wth Seven- One-nght- Three 13-hour nghts-n- Four- Two-two- at-a-tme nne-hour weekend Name of rota successon and-three and-three weekday shfts shfts Table no Maxmum no. of consecutve nght shfts worked Maxmum no. of consecutve nght shft hours worked Maxmum no. of consecutve days worked Maxmum no. of consecutve days off No. of unbroken weeks of daytme work on base team No. of weekends worked wthn cycle Average fatgue 36, * 11.7 Maxmum fatgue 36, * 51.3 Average rsk 36, * 0.93* Maxmum rsk 36, * 1.42 * Best rota. 18

23 APPENDIX 1 Practcal tps for desgnng rotas Basc prncples Involve the staff who wll be workng a rota n ts desgn. A rota that s forced upon reluctant workers s unlkely to be successful. Remember that ncreased tme workng a shft s assocated wth an ncreased rsk of accdent or njury. Workng at nght further ncreases ths rsk. Three nne-hour shfts to cover 24 hours should mprove health, safety, teachng and supervson, and effcency. Allow suffcent tme off after nght shfts to allow proper recovery and to allow doctors to catch up on sleep. For every two nghts on duty, at least one whole day off should be scheduled. Remember that workng more than four nghts n a row s nether pleasant nor, n our vew, advsable. Drawng up the rotas Consder what the mnmum medcal staffng requrements for a smoothly runnng rota are lkely to be, and then try to nclude more doctors than ths mnmum. Do not desgn rotas that nvolve workng rght up to the maxmum allowable number of hours per week. Doctors wll almost nevtably end up on occason beng on duty for longer than they are scheduled to be, so take ths nto account when decdng the length of shfts. Thrteen-hour shfts wll almost always overrun, threatenng to trgger Band Three payments and, unless compensated, a breach of the Workng Tme Regulatons. Start by plottng out the nght shfts, and then add n the necessary days off. Group nght shfts together on Frday, Saturday and Sunday nghts; ths makes the most effcent use of a doctor s tme. Workng on just a Saturday or Sunday nght wll ncrease the number of doctors needed to cover a weekend, and wll also make t more dffcult to comply wth the New Deal rules. Once you have flled n the nghts and days off, fll n the gaps wth days. Contnuty of care Make sure that the rota ncludes suffcent tme for a comprehensve handover (up to an hour, dependng on the specalty) and that the rota allows all members of the team to be present. 19

24 Desgnng safer rotas for junor doctors Try to desgn rotas wth doctors n pars, so that when one s on nght duty another n the same team s stll avalable for day work. Consder matchng-up doctors so that handovers mantan contnuty. For example, run blocks of days and nghts together, so that the same doctors are handng over to each other more than once. Do not forget the balance between contnuty of care, the safety of any rota, and how dsruptve the rota s for the doctors beng asked to work t. 20

25 APPENDIX 2 Members of the Workng Group Speakers Professor Smon Folkard, Unversté René Descartes, Pars Dr Chrstopher P Landrgan, Brgham & Women s Hosptal & Harvard Medcal School, Boston Dr Steven W Lockley, Brgham & Women s Hosptal & Harvard Medcal School, Boston Dr Deborah Powell, New Zealand Resdent Doctors Assocaton Dr Barbara Stone, Centre for Human Scences, QnetQ Members of the Workng Group and contrbutors The followng people were members of the Workng Group or contrbuted to the development of ths gude. Dr Peter Alexander, Intensve Care Socety Tranees Commttee Dr Mke Page, Consultant Physcan, Royal Glamorgan Hosptal Dr Mary Armtage, Clncal Vce-Presdent, Royal College of Dr Amt Patel, Tranees Commttee, Royal College of Physcans Physcans Dr Jane Pateman, Assocate Dean, London Deanery Professor Mchael Bannon, Postgraduate Dean, Oxford PGMDE Dr Dlp Raje, Patent and Carer Network, Royal College of Physcans Mr Mke Beatte, Senor Busness Manager, Doctors Team, NHS Mss Wendy Red, Postgraduate Dean, London Deanery Employers Dr Mark Roberts, SpR n Respratory Medcne, Derbyshre Royal Professor Dame Carol Black, Presdent, Royal College of Physcans Infrmary Mr Stuart Blackwell, Royal College of Physcans, Patent and Carers Forum Dr Declan Chard, Char, Tranees Commttee, Royal College of Physcans Ms Sarah Connelly, Head of Medcal Workforce Development, North Central London SHA Dr Robert Coward, SpR Advsor, Royal College of Physcans Professor Sr Alan Craft, Presdent, Royal College of Paedatrcs & Chld Health; Charman, Academy of Medcal Royal Colleges Dr John Curran, Royal College of Anaesthetsts Mr Roger Curre, Royal College of Surgeons (Ednburgh) Ms Lndsey Dawson, Health & Communty Care Research Unt, Unversty of Lverpool Ms Sue Dean, Assocate Drector, NHS Workforce Projects Mr Andrew Drakeley, Char, Academy of Medcal Royal Colleges Tranee Doctors Group Professor Bll Dunlop, Char, Jont Consultants Commttee Mr Smon Eccles, Natonal Clncal Lead for Hosptal Doctors, NHS Connectng for Health Mr Martn Else, Chef Executve, Royal College of Physcans Mr Paul Evans, NHS patent Dr Sara Farbarn, Tranees Commttee, Royal College of Physcans Dr Anna Forrest-Hay, Faculty of Accdent & Emergency Medcne Dr Ashley Fraser, Medcal Drector, NHS Employers Dr Clve Lews, Deputy Char, Tranees Commttee, Royal College of Physcans Dr Rchard Long, Censor, Royal College of Physcans Professor John Lowry, Royal College of Surgeons (England) Dr Andrew Mtchell, Royal College of Paedatrcs & Chld Health Ms Alce Murray, Medcal student, UCL Dr Andrew Rowland, Deputy Charman, UK Junor Doctor s Commttee, BMA Mr Dean Royles, Head of HR Capacty & Employment, NHS Workforce Drectorate Ms Joan Russell, Safer Practce Lead, Natonal Patent Safety Agency Dr John Scarpello, Deputy Medcal Drector, Natonal Patent Safety Agency Dr Mark Smmonds, SpR n Medcne, Queen s Medcal Centre, Nottngham Mr Domnc Slade, Secretary, Assocaton of Surgeons n Tranng Dr Davd Snashall, Presdent, Faculty of Occupatonal Medcne Mrs Elane Stevenson, Safer Practce Lead, Natonal Patent Safety Agency Dr Arvndan Veraah, SpR n Clncal Pharmacology, Llandough Hosptal Dr Chand Vellod, Councllor, Royal College of Physcans Mr Jm Wardrope, Presdent Elect, Faculty of Accdent & Emergency Medcne Mr Rchard Warren, Honorary Secretary, Royal College of Obstetrcans & Gynaecologsts Mr Davd Wells, WTD Lead, Maternty & Paedatrcs, Care Servces Improvement Partnershp Mss Melssa Whtten, Char, Royal College of Obstetrcans & Gynaecologsts, Tranees Commttee Dr Martha Wyles, Char, Tranees Commttee, Royal College of Paedatrcs & Chld Health Mr Robert Wykes, Royal College of Physcans, Patent and Carers Forum Dr Sashdhar Yelur, SHO Surgcal Rotaton, St James Unversty Hosptal, Leeds 21