NHS crisis makes training records all the more vital
The NHS is struggling again. A&E waits are rising, outpatient departments increasingly miss their targets for urgent patients, and more people with cancer are waiting longer for potentially life-saving treatment. The reasons for the evolving crisis are controversial, with health ministers pointing the finger at rising demand, and medical doctors more likely to highlight poor strategic decisions in NHS management, particularly primary care.
Whatever the cause, it is clear that trainees in the hospital acute specialties face a rising service delivery workload, and the risk is that there will be less time available for training. Some of the changes in the new NHS junior doctor contract will interact with this trend in interesting ways. Two aspects of the new contract require special consideration:
First, junior doctors’ standard working week is effectively being reduced. Although under the “old” contract there was the potential for basic 40hr week, very few doctors were employed on this basis; most juniors were employed on contracts providing for an average of 48hrs work per week. The new arrangement implements a basic 40hr week across the board with any extra hours added at an hourly billable rate. This is a big psychological change, if nothing else: hospital trusts, used only a vague and imprecise relationship between doctors’ hours and pay, are suddenly to be confronted with a direct and incremental cost if they don’t reduce junior doctors’ rostered hours from 48 to 40 per week. Given that hospitals’ clinical workload is constant or increasing, this cut in working time will likely come from discretionary content such as educational activity.
The second relevant provision of the new contract is the “Guardian of working hours” and its’ supporting management structures. As part of this, each junior doctor will enter into an enforceable educational agreement with pre-specified time identified in their work timetable as “educational”. At face value this seems a big advance on the current vague stipulation that training posts should include some educational content. If educational agreements are well drawn up, with educational opportunities appropriate to the individuals’ seniority and specialty then this could work well. However, as the borders of what is considered “educational” are not contractually defined, the concern is that employers who currently struggle to provide educationally useful posts will just use the educational agreements as a smokescreen to disguise sub-standard jobs by labelling service provision components as “educational”.
Naturally the service / training dichotomy is an over-simplification, as all but the most humdrum of medical practise has an educational component, even if only in dredging up rubrics and practical skills learnt long before.
Nonetheless, it is clear that the new contract, in combination with increased demands on the service, is going to put a new responsibility onto juniors to prove how they are spending their time. Imagine attending an annual training review after 10 months in a job where the educational agreement says you have access to four operating lists per week, with only 40 operations in your logbook: the review panel would be justifiably unimpressed. The reality may well be that your “supervisor” has consistently elbowed you out of the way to get cases done quickly, and that you could only attend 1/4 of the lists to start with due to covering gaps in an understaffed on call rota. Without proof, however, you are skating on very thin ice.
In this brave new NHS world, a comprehensive clinical logbook has never been more important.
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