I started my foundation year 1 (FY1) post last year full of negativity about the new junior doctor contract being enforced. My expectations were that I was going to be valued less and paid less than my predecessors. However, unexpectedly, my experience was empowering and motivating. Whether this was because I was fortunate enough to be working at a district general hospital that actively embraced the contract’s implementation, or whether this has been a more general experience, time will tell.

Exception reporting initially struck me as yet another bureaucratic process of little benefit, but the reality proved somewhat different. A high number of exception reports in my trust has already triggered several quality improvement projects. Exception reporting was so high on one ward that we are now trialling a doctors’ assistant to reduce doctors’ workload there.

Similarly, time spent waiting for blood test results and a lack of phlebotomy cover were cited as reasons for working beyond contracted hours in approximately 20% of our exception reports.¹ Consequently, our junior doctors’ forum (JDF) is working with management to redesign and expand phlebotomy cover.

One of the advantages of exception reporting is that, unlike ad hoc diary card exercises, it enables us to highlight in real time any problems developing on the shop floor. These exception reports are presented to the trust board and should inform their strategic decisions.

Another important initiative in the contract is the creation of the position of guardian of safe working hours and the aforementioned JDF. We now have the ability to influence executive decisions that are relevant to our working lives. Our hospital’s JDF, for example, has facilitated changes to our work schedules. There was an uneven workload distribution between the surgical subspecialties, and we were often working beyond our paid hours. The JDF supported our discussions with management and senior doctors, and these negotiations were remarkably constructive. We agreed that there would be greater standardisation of hours in surgery and an increase in our contracted hours to reflect the hours we actually worked—a remarkable success!

Another pleasing development is that the 2016 contract acknowledges the pivotal role of training within our placements. This is fundamentally important: we are doctors in training, not just service providers. Now, if we discover that our work schedules do not provide adequate training opportunities, there is a formal process to escalate this within the trust.

However, it is not all plain sailing. The system is intrinsically flawed, as the consultant is inevitably cast as piggy in the middle: stuck between supporting their juniors, appeasing management, and showing their department in a good light. Our consultants require great objectivity to rise above these conflicting pressures and to not apply pressure to juniors to abstain from exception reporting.

We also need to consider the impact that a rejected exception report can have. Individual doctors and teams can be damaged by this denial and the implied (if not verbalised) criticism of their efficiency and integrity. It is notable that there was a significant decrease in exception reporting before the annual review of competence progressions (ARCPs) took place.² Could it be that we were less likely to exception report due to the requirement for positive assessments from our consultants?

Pay has been another contentious issue. I am not sure whether all parties have completely grasped the fundamental change in how our salaries are calculated. We are now paid hourly—banding has been relegated to history. As we discovered at my hospital, this means that small discrepancies between rostered hours and work schedules can result in substantial underpayments. For surgical FY1s (of which there were 10), the average discrepancy was 2¼ hours per week, amounting to an underpayment of £1449.25 per annum. For medical FY1s (of which there were 16), the difference was one hour per week, resulting in an underpayment of £658.75 per annum.

These remarkable discrepancies were caused by errors in the manual entry of data (surprisingly, work schedules are created by manually inputting the rota shifts into work scheduling software) and the omission of bank holidays and annual leave allowances from the calculations. Our guardian of safe working hours supported the JDF in sharing these findings with the human resources and payroll departments. Fortunately, they promptly corrected these issues: we are now paid correctly.

The 2016 contract provides us with many opportunities, but for them to be realised it is fundamentally important that we understand the possibilities and engage with them. We need to take ownership of our work schedules and challenge inaccuracies. We need to be in a position where we have the headspace, confidence, and enthusiasm to engage with the JDF—otherwise all these powers fall by the wayside. Crucially, we also need an active guardian of safe working hours and a hospital that is willing to listen.

We have been given new rights, don’t let us waste them.

References

1. Twenty four of 103 exception reports cited a lack of phlebotomy cover or a lack of timely blood results as a reason for working beyond contracted hours. Exception reporting data from Whittington Health between 7 December 2016 and 4 April 2017.
2. Exception reporting data from Whittington Health. The first ARCP date was 05/06/17. Between 06/05/17 and 04/06/17 there were only two exception reports; compared to 35 in the 30 days prior to this period, and 36 in the 30 days after this period.

Emma Cox is a foundation year 2 doctor. She was a member of the Whittington Health JDF as a foundation year 1. She also ran a conference on the 2016 contract in July 2017 called “The New Contract: the good, the bad, and the ugly.”

Acknowledgment: With thanks to Vidushi Golash and Caroline Fertleman for their contribution.

Declaration of interests statement: I have read and understood BMJ policy on declaration of interests and declare the following interests: I ran a conference entitled “The New Contract: the Good, the Bad, and the Ugly” and was previously a member of Whittington Hospital Junior Doctors’ Forum.