Flexible training under the new deal

Increasing numbers of women are qualifying in medicine—50% of house officers and more than half of medical school entrants are female.¹,² Most of these doctors will marry and have children, and up to 70% would like to work part time at some stage of their careers.^3–5

Opportunities for part time training have improved vastly since the first scheme was launched in 1969, and the changing regulations have allowed the number of flexible trainees to increase to 1200 in 2001, which represents 7% of all specialist registrars.¹,⁶,⁷

Part time training is not restricted to women with children—anyone with well founded reasons can apply—but they form by far the largest group.⁷ Forty three per cent of women doctors marry doctors.³ Even more than in other families where both partners have careers, doctors face particular problems of shift work, on-call commitments, and geographical mobility.

If part time work were unavailable, the alternative for many of these women doctors would be to leave the NHS either for some time or forever.³ At a time when the government is looking for an additional 7500 doctors, the NHS cannot afford such losses.⁸

Flexible training is, however, under threat. The new pay deal—which was intended to bring improved working hours and conditions to junior doctors, with (at last) fairer remuneration for long hours of work—has had the opposite effect on flexible training.⁹ Since the new pay deal was implemented on 1 December 2000, trusts in all regions have become unwilling to take flexible trainees. Flexible trainees have experienced refusal to accept them (even on a planned rotation), non-renewal of their contracts, and refusal to allow conversion from full time to flexible training.

The reason, of course, is money. Under the new arrangements, trainees working less than 40 hours a week in posts compliant with the new deal are remunerated in band F; for most, this represented a considerable pay rise, which was implemented overnight instead of being staggered, as it was in other bands.¹⁰ Moreover, a substantial number of flexible trainees are paid above band F, either because they work more than 40 hours a week or because they are working in posts that do not comply with the new deal. In obstetrics and gynaecology most flexible trainees are in “illegal” posts, with inadequate hours of rest while doing on-call duty. Non-compliant posts are automatically banded at level 3—regardless of the actual hours worked—and incur a fixed level of remuneration designed to penalise the employing trusts. It is no wonder that trusts refuse to take flexible trainees.

The requirements of the new deal have now driven junior doctors into patterns of shift work that are completely replacing the traditional rota system in specialties of high intensity such as emergency medicine and obstetrics. These are unpopular with trainees because of the lack of continuity of care and impact on family life, and shifts are particularly difficult for flexible trainees who need to make childcare arrangements around early starts, late finishes, and varying weekly hours.¹¹ Where facilities for hospital nurseries exist, their opening hours may not cover shift work. Live-in help may be needed to cover a week of nights.

How can this situation be improved? Firstly, flexible training posts must be made compliant with the new deal as soon as possible. Deaneries are now insisting that all new posts are in band F. Deaneries can work with trusts—for example, the appointment of full timers can be linked to acceptance of part timers. After all, any specialist registrar has the right to request flexible training at any stage.⁷ But even when the nirvana of compliance with the new deal has been achieved for all, flexible trainees will still cost trusts more per hour than full timers.

Secondly, this crisis presents an opportunity to reconsider out of hours training. This has always been driven by the need to cover the services offered by the NHS for 24 hours a day, 365 days a year. Exposure to emergency medicine out of hours is undoubtedly valuable, but perhaps the colleges could consider how much is needed to acquire competence.

Thirdly, the NHS must make good its pledge to promote family friendly policies. The audit standards set out in Improving Working Lives require trusts to show evidence of support for flexible training.¹² Encouragement to trusts from the Department of Health has recently been made more persuasive with financial backing. The Department of Health has identified an additional £7m (€11m; $10m) to enable deaneries to make a greater contribution to flexible training salaries from August 2002, and a further £7m will be available in 2003-4. This will, however, not be sufficient to support all flexible posts, and innovative methods of funding must be explored. Alternatively, the scope for renegotiating the new pay deal in relation to flexible training must be considered. It cannot have been the intention of the original negotiations to cause the current crisis, which has threatened the careers of many flexible trainees.