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| Journal of the New Zealand Medical Association,
22-October-2004, Vol 117 No 1204
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Resident Medical Officer working conditions in
New Zealand: results of a recent survey
Stephen Child, Andrew Old
Health systems worldwide are facing significant challenges
with regards to junior doctor staffing. In part, these difficulties have arisen
from the need to reduce the inappropriately long hours traditionally worked by
junior doctors. As junior doctors working hours have decreased, most hospitals
have responded to the change by increasing the numbers employed. Additional
pressure has come from increased patient demands and changing methods of service
delivery that have further fuelled the need for greater numbers.
In most Western countries, this increased need for junior
doctors has outstripped the supply of new medical graduates resulting in
worsening shortages. More recently, the European Working Time Directive (EWTD)*
has been enacted which requires the average weekly hours of work of junior
doctors in Europe to be no more than 58, by August 2004. The United Kingdom
alone has estimated the need for an additional 15,000 doctors to staff the
National Health Service (NHS) to meet this directive, and most commentators are
predicting a prolonged period of non-compliance due to an inability to recruit
in sufficient numbers. A recent Royal College of Physicians survey estimates
that only 23% of Trusts (District Health Board equivalents) will be compliant
with the EWTD1 while a second article notes a
greater than 400% increase in non-consultant career grade doctors (Medical
Officer of Special Scale (MOSS) equivalents) in the 10 years to
2001.2 Similar reports from Ireland, Germany,
and the Netherlands predict difficulties with EWTD compliance while France,
Spain, and Slovenia have requested an exemption from this
legislation.3
In New Zealand, junior doctor working conditions are
prescribed by a national contract negotiated between the District Health Boards
(DHBs) and the Resident Doctor union, the New Zealand Resident Doctors
Association (NZRDA). Current working conditions are arguably the best in the
world and, in most cases, DHBs are already compliant with the EWTD. Many DHBs,
however, have complained about the dramatic increase in junior doctor staffing
required for contract compliance, and have voiced concern over the negative
impact on training and lack of flexibility in the contract provisions. These
concerns are shared with their counterparts in the United Kingdom who are
grappling with similar issues in attempting to come to terms with the
EWTD.3,4
For this article, we conducted a small survey of the views
of junior and senior doctors on 11 aspects of the current contract at the
Physicians Grand Round at Auckland District Health Board (ADHB).
*EWTD: A
directive from the Council of the European Union (93/104/EC) to protect the
health and safety of workers in the European Union. It lays down minimum
requirements in relation to working hours, rest periods, annual leave, and
working arrangements for night workers. The Directive was enacted in UK law as
the Working Time Regulations, which took effect from 1 October 1998. The WTD
applied to all workers with a few exceptions, including doctors in training.
From August 2004, it will be extended to apply to these doctors, although the
provisions will be phased in with a maximum hours requirement reducing from 58
hours in 2004 to 48 hours in 2009.
MethodsADHB is the largest tertiary
healthcare provider in New Zealand. It employs 487 junior doctors, which is
roughly 26% of the current New Zealand junior doctor workforce. ADHB holds a
weekly Physicians Grand Round which is open to all medical, nursing, and allied
health staff.
In April 2004, a grand round was held to discuss junior
doctor working conditions. Special advertising was produced, inviting junior and
senior doctors to the discussion. Electronic keypad responders ensured that all
senior and junior doctors present were able to express their individual opinions
anonymously.
Eleven multiple-choice questions were asked of the
audience, with each question preceded by a discussion of the individual issue
presented. The audience was asked to pick their preferred answer using the
keypad responders, with the results immediately collated and displayed. A brief
summary discussion was held following each question. All results were then
combined in a spreadsheet and are presented below.
Results are reported as count (percentage) or
proportion (95% confidence intervals). Differences in proportions were compared
using a chi-square test. Non responders were not included in the analysis and a
p-value less than 0.05 was considered statistically significant. All analysis
was performed using SAS statistical software.
ResultsMore than 100 people attended the
presentation, and 70 keypad responders were distributed to the audience. Of the
70 keypads distributed, 27 responders identified themselves as junior doctors
(Resident Medical Officers/RMOs) and 32 as senior doctors (Senior Medical
Officers/SMOs), with 11 recorded as ‘Other’.
The SMOs consisted primarily of physicians representing the
departments of critical care, general, and sub-specialty medical groups around
the hospital. Similarly, the RMOs were primarily medical registrars and house
officers with little or no surgical representation. Most were post-graduate year
2 or greater, with many having worked in more than one DHB in New Zealand. Only
the results from those identifying as doctors are presented here.
Perspectives on working structure (Table 1)Nights—A
discussion was held regarding the restrictions on first year probationary house
officers (PGY1) working nights in their initial employment period. Respondents
were offered options of status quo (6 month restriction), shorter restriction
periods that differentiate between tertiary and secondary hospitals, deletion
from the contract with discretion left to the Medical Council, or
‘other’ (Table 1).
Table 1. Perspectives on working structure
14 (52%) of the RMOs preferred no night duties for the first
6 months of employment compared to just 4 (13%) of SMOs. The majority of SMOs
(71%) favoured a shorter and variable restriction period as indicated (Table 1,
Figure 1).
Figure 1. Restricted period in which PGY1 House
Officers cannot do night shift
 Respondents were also asked their opinion as to the maximum
permissible number of consecutive nights an RMO should be allowed to do. The
majority of RMOs (62%) favoured a restriction to a maximum of 5 nights whereas
SMOs were evenly divided between a restriction to either 7 or 5 nights (Table
1).
Relief notification
period—To cover leave provisions, DHBs employ dedicated
‘leave relievers’ who are RMOs hired for the sole purpose of
replacing other RMOs on leave.
Currently the contract states that relievers must be given
14 days notice of any duty. Following discussion, respondents were given the
options of the status quo, or for the notice period to apply to after hours
duties only, with relievers not allocated being available for work, Monday to
Friday 0800–1600.
Both groups favoured the notification period to apply only
to after hours duty with the RMOs favouring 14 days notice of such duties (62%)
and the SMOs favouring 7 days notice (62%) (Table 1, Figure 2).
Figure 2. Notification required to work when allocated
as a reliever
 24-hour
on-call—The current contract does not permit RMOs to be rostered
for more than 16 hours duty in any situation unless an exemption is granted by
the union. The terms for such an exemption are not defined but informally, the
union will only grant an exemption if the frequency of any calls between
midnight and 8 am is less than 2–3 calls/week.
Following discussion, respondents were offered options of
the status quo or to permit 24-hour call if the frequency of calls was less than
2/night, or to permit 24-hour call if the frequency of such on-call periods was
greater than 1:5 and if there was an average of 4 hours rest per night on-call.
Emergency provisions would need to be in place if less than 2-hours’ sleep
was achieved and theatre and clinics would be cancelled the day following such
call periods. A fourth option was provided that 24-hour call should never be
permitted.
RMOs primarily favoured the status quo (48%) however a
significant number (26%) also favoured the complete abolition of 24 hour call.
SMOs however clearly supported the concept of 24 hour call with restrictions as
noted by the second and third options presented above (69% combined) (Table
1).
Weekend roster
pattern—Respondents were asked their opinion regarding weekend
rostering. The current contract states that RMOs must be free of duties every
alternate weekend.
Respondents were offered the choices of status quo, a change
to 50% of weekends rostered off† or the concept of rotating weekends with
48 hours rostered off in a 14-day period but not necessarily assigned to weekend
days.
The majority of RMOs (77%) favoured the status quo with
alternate weekends off, whereas a similar majority of SMOs (63%) favoured a
change to 50% of weekends rostered off (Table 1, Figure 3).
†A minimum of 50% of weekends off across the
rotation—eg, 7 weekends off out of 14, but not necessarily every second
weekend off as per the status quo.
Figure 3. Weekend roster pattern
 Weekdays rostered
off—The current contract states that regardless of duties worked,
RMOs must be paid for a minimum of 8 hours duty Monday to Friday between the
hours of 0730–1730.
Following discussion, respondents were offered the options
of the status quo or a change that would allow weekdays to be rostered off.
Options included weekdays rostered off with roster monitoring left to the
accreditation authorities for education or only on rosters where SMOs were also
working similar shifts.
RMOs appeared evenly split between all three options (40%,
28%, and 32% respectively), however a majority (60%) supported the concept of
rostered weekdays off in some form. SMOs more clearly favoured rostered weekdays
off (80%) with a trend toward external imposition by accreditation (Table
1)
Maximum hours per
week—Following discussion, respondents were asked their opinion
regarding the maximum hours that should be rostered in any 7-day period. SMOs
appeared to favour a 72-hour maximum (54%), with 60 hours per week the most
popular option for RMOs (43%). The difference between RMOs and SMOs however was
not significant (Table 1).
Perspectives on meals structure (Table 2)Respondents were asked their
opinion as to the ideal delivery method of the contract clause entitling RMOs to
a meal while working over a recognised meal break.
RMOs appeared evenly divided between unlimited access
(status quo), a transferable voucher system, daily dollar limit, or direct pay
supplement (22%, 26%, 19%, and 26% respectively). SMOs significantly favoured
the ‘other’ option (40% compared to just 7% of RMOs) and when asked
in discussion, believe that RMOs should pay for their own meals and that this
entitlement should be deleted from the contract (Table 2).
Respondents were then asked for their opinion on a
reasonable dollar limit if that option was to be chosen, with the majority of
RMOs (52%) opting for a NZ$10/meal restriction and the largest number of SMOs
(43%) opting for an $8/meal restriction (Table 2).
Table 2. Perspectives on meal structure
Perspectives on remuneration methods (Table 3)Currently RMOs in New Zealand are
paid on a salary band system. When RMO rotations are introduced or changed, RMOs
are asked to keep a log book of hours worked and then pay is related to the band
of average hours worked.
Following discussion, respondents were offered retention of
the status quo or a change of remuneration methods. Options included a base
salary plus hourly rate for after hours worked (as in Australia), a base salary
only (as in the USA), or a pure hourly rate. The majority of RMOs (52%) favoured
a base salary plus hourly overtime, while SMOs were fairly evenly split between
the other options (Table 3). Differences between the groups, however, were not
significant.
The audience was also asked about reimbursement of
vocational training costs and what they considered to be reasonable. Options
given were: the status quo—unlimited reimbursement of all costs incurred
on the pathway to vocational registration; a dollar cap annually or per training
programme; a capped number of training items (eg, textbooks, courses, etc); or
‘other’. RMOs’ most preferred option was the status quo (50%)
while their senior colleagues preferred the concept of a dollar cap (72%)
(Table 3, Figure 4).
Table 3. Perspectives on salary
administration
Figure 4. Reimbursement of vocational training
costs
 DiscussionIn this study, we surveyed a small
group of RMOs and SMOs regarding the working conditions of RMOs in New Zealand.
Given the survey was conducted at the Physicians Grand Round in a major tertiary
hospital, it should be noted that the views of those surveyed may well differ
from members of other specialities and from those of doctors working in smaller
centres.
New Zealand employs approximately 2,700 SMOs and 2,000 RMOs.
This survey, therefore, sampled only about 1% of doctors in this country and
cannot be seen to be representative of the views of the majority. The sample
size does, however, permit comparison of the two professional groups—and
the results raise interesting points of discussion regarding RMO working
conditions and the current relationship between RMOs and SMOs.
Most countries of the Western World have been actively
moving to reduce the hours worked by RMOs in training, with the result that
(over the last two decades) we have witnessed a gradual reduction in the average
number of hours worked per week. In most of these countries, the change has been
brought about through legislated change or via the residency accreditation
processes. The introduction of the EWTD, for example, has created a short,
definitive timetable for the introduction of changes to the healthcare systems
of Europe—including Britain’s National Health Service (NHS), one of
the largest healthcare systems in the world. As a result, many of the common yet
complex issues involved in reduction of RMO working hours are having to be
urgently addressed within the United Kingdom.
New Zealand has produced a set of national working
conditions through employer/union contract negotiations held at regular
intervals. These negotiations have resulted in limits on hours that are some of
the lowest in the world, with average hours at 56–58 per week. The current
multi-employer collective agreement (MECA) is a ‘one size fits all’
document, breaches of which can result in industrial or legal action. Over the
years, hospital management, SMOs, and RMOs have expressed concern at the
rigidity of the single solution while, at the same time, applauding the
improvements compared with historical junior doctor
hours.6 Issues such as the length and quality
of training have become important points of discussion within a very complex
milieu.7
In our study, RMOs appeared to support the continuation of
the current contract provisions regarding:
RMOs surveyed appeared to disagree
with the current contract position on the issues of:
A less definitive RMO opinion was
expressed on the issues of:
Most importantly, and of
significant concern, was the disparity in viewpoint between SMOs and RMOs on the
issues of:
It is of serious concern to any
profession when there develops a widening gulf between its senior and junior
members. It is of even greater concern in an apprentice-style training program
in which juniors are expected to receive training, education, and guidance from
more senior members of the profession. Any divergence in views on ways of
working could have a significant detrimental effect both on the provision of
training and hence the quality of healthcare professionals in the future, as
well as service delivery to the public of New Zealand.
This study is small and cannot be used for wider
generalisations. It does, however, highlight potential discrepancies between the
viewpoints of various stakeholders to the provision of healthcare and training
in New Zealand. The structure of junior doctor working conditions is fundamental
to the delivery of care within a hospital system. Any change to roster patterns
for example, can result in an undersupply of RMOs for created positions and
hence shortages, unsafe work practices and flow on effects to all aspects of the
healthcare system.
In the United Kingdom, Canada, United States, and Australia,
professional bodies are meeting with government and hospital employers to openly
discuss these issues in an effort to come up with agreed solutions to what is a
very complex situation.
This study suggests that there may be differences of opinion
in New Zealand that are not captured by the current employer-union process that
require frank and open discussion. The authors believe that the profession
should take ownership of these issues, and the views of all stakeholders should
be sought through wider processes such as national conferences, surveys, or
other such mechanisms. This information could then be used to develop
appropriate strategies to address these differences and their
implications.
Author
information: Stephen Child, Director of
Clinical Training; Andrew Old, Senior House Officer, Auckland District Health
Board, Auckland
Correspondence: Dr
Stephen Child, Director of Clinical Training, Auckland District Health Board,
Private Bag 92024, Auckland. Fax: (09) 623 6421; email: Stephenc@adhb.govt.nz
References:
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