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One of the many reasons I was keen to work in Australia was to see if they really had achieved what we're told they have—the legendary forty-hour working week. More to the point, how have they reconciled that magical triumvirate: Service, Education, and the often overlooked Having a Life. Let me start by saying that I think that they have achieved it, to some extent, but that I don't quite understand how.
The agreements between junior doctors and their employers are at state level in Queensland, but there are a few generalisations that can be made. Firstly the contract is to 40 hours per week—well, in fact, 80 hours per fortnight. Secondly the employer suffers a series of financial penalties for asking doctors to work antisocial hours or patterns. These range from 15% extra for night shifts, to double time for Sundays, to 250% for some public holidays, with many shades of grey between. For example, if you work any overtime or more than 10 hours in a day your hourly rate rises, at this point, to 150% basic. If you were on what we might understand as a full shift roster, you'd be on 200% for any overtime. In any case, after three hours of overtime you're on 200%. Confused yet? The Queensland award and interpretation runs to more than 100 pages.
The employer is, therefore, under a large financial pressure to introduce more reasonable—and thus for them cheaper—working patterns in this more sophisticated version of what is being attempted with the banding system in the UK. However, they do have a powerful trump card to play. “Remote on-call”, in Queensland at least, requires a doctor to be available for work at 30 minutes' notice. This means, at the very least, staying in town, contactable and sober. For this the doctor is paid just a few dollars a day. Of course, once they are called in they are immediately on penalty rates of pay, but this provision does allow an employer to roster doctors quite tightly, and pay an almost negligible amount for peace-of-mind backup for busy times or sickness.
Now education. In the UK I've heard the argument, expressed by apparently sensible people, that unless they work the odd 30 hour shift they can't possibly “get experience.” My Australian colleagues express incredulity at this: “What? Experience of feeling rooted?” they ask—rooted being a euphemism for “very tired”. It seems accepted that you work some bunches of nights, during which you're tired and feel rotten. However, you do most of your learning the rest of the time, and you learn because you are not tired, are (for the most part) adequately supervised, and because you have the time, space, and inclination to study.
What about having a life? I mostly worked 3 different patterns in Australia. In my first placement, on an oncology unit, I worked nine-to-five—really eight to six, with every fourth Friday evening until 10, and every fourth Sunday, thirteen hours. I had to hide my smile when they paid me extra for staying late (I was still in British doctor mode) and had to remind myself to write it all down. One week in eight I was on remote on-call, as described above, but I was only called in once in four months. And yes, I had a life. I could even go out in the evening, plan weekends, buy cinema tickets, and even stay awake during the film... . My next pattern was shifts on a paediatric intensive care unit, which was much more disruptive. The upside was the greatly increased pay from all the penalties, enabling me to do a great deal with the little free time I did get. I should add that this was a full roster covered (non-prospectively) by just four people, and therefore unlikely to be replicated in the UK, where at least six or seven people are felt to be the point at which a shift system can be introduced. Lastly I shared an old fashioned one in two with a consultant in a remote country town. Again, not hugely conducive to getting out and about—both the roster and the isolation—but financially rewarding, which I made good use of.
As stated, I think it works in Australia. But how would I import the legend to the UK? This has clearly defeated better minds than mine, but I'd suggest that to get a true improvement, we need a fundamental shift in our attitudes.
Firstly, we've got to get over our night shift hang-ups. Reasonable clusters at reasonable intervals are tolerable, and allow you to provide a lot of service for not too much life disruption. Ditch, also, the idea that you learn a great deal at night—unless learning from your mistakes is your preferred method of learning. Make it up to people by teaching them even better during the day. Make handover a time where doctors are both accountable for their actions, and educated.
Secondly, if someone is going to sit around for long periods, let them sit around at home, or somewhere else. Don't pay them full time for this, but do give them a bit more than the Aussies. Then, if you need them, pay them properly for their trouble. You'd pay a plumber £75 an hour at a weekend if you called them, wouldn't you? But you wouldn't expect to pay him an hourly rate for the rest of the 24 hour period.
Thirdly, I don't think people mind working overtime if this is recognised—that is, that they're paid for it. It alters your perception of staying late (you don't write down every minute, but you are reasonably rewarded for times when you need to work harder) and your employer rapidly recognises when you are being worked too hard.
Lastly, although a very great part of my life is paediatrics, this isn't the same as A Life. A Life means—well, I'm not sure what it means, but I think it is something to do with not being tired all the time, being loving to the people you love, and having time for things outside of work. Until we all appreciate that, we're going to have a long a difficult struggle.