F H French, J E Andrew, M Awramenko, H Coutts, L Leighton-Beck*, J Mollison+, G Needham, A Scott**, K A Walker
NHS Education for Scotland, North Scotland Region, Forest Grove House, Foresterhill Road, Aberdeen;
*Public Health Directorate, NHS Grampian, 181 Union Street, Aberdeen; +Department of Public Health, University of Aberdeen,
Medical School, Foresterhill, Aberdeen, **Health Economics Research Unit, University of Aberdeen, Medical School, Foresterhill, Aberdeen
email: Fiona.French@nes.scot.nhs.uk
SMJ 2003 49(1): 47-52
Abstract
Background and Aims: UK consultants have reported working long hours, increased stress and reduced morale. This study set out to elicit consultants’ views on flexible working and to gather data on consultants’ workloads, remuneration, job satisfaction and retirement plans. As such it is the first comprehensive study of consultants in NHSScotland. Methods: The Information and Statistics Division of the Scottish Executive Health Dept provided a list of consultants working in NHSScotland. Focus groups and interviews informed the design of a postal, self-completion, questionnaire.
Results: The response rate was 61%. Almost two-thirds (65%) of respondents felt their workloads were unreasonable and unsustainable and 67% were unable to provide their desired standards of patient care. Two-thirds (67%) did not normally take meal breaks, 63% had insufficient time for outside interests, whilst 44% felt their health was being adversely affected. Many (84%) believed that some of their work could be delegated to someone less qualified but 79% agreed that there were insufficient staff to make this possible. The average planned retirement age was 60 years, with 23% describing their plans as definite and 70% as quite or very likely. When asked what might induce them to postpone retirement, 50% cited reduced workload/work intensity. Conclusions: In 2003, a majority of consultants in the UK voted in favour of the new consultant contract. This will improve consultant pay and introduce a standard 40-hour working week, including worked on-call. This should address tow of the main areas of consultant dissatisfaction in NHSScotland. However, staff shortages will require to be addressed if the contract is to be successfully implemented.
Key words: Consultants, workload, job satisfaction, remuneration, gender, retirement plans, questionnaire survey
Background and aims
The UK Governments are committed to providing a consultant-led National Health Service (NHS). However, in recent studies, UK consultants have reported heavy workloads, increased stress, reduced morale and plans for early retirement.1,2,3,4,5,6 Many doctors now seek a better work/life balance, supported by the gradual implementation of the European Union Working Time Directive. However, whilst the New Deal7 and reforms of medical training 8,9,10 have improved conditions for many doctors-in-training, they have also served to increase consultants’ workloads.1 This has come at a time of increased patient demand and pressure to meet short-term government targets. Annual appraisals for consultants have been introduced and revalidation is on the horizon: these will add to consultants’ existing workloads. Previous studies of UK consultants have focused on a single specialty,3,4,5,11,12 a small number of specialties13 or particular age groups.14 Other studies have been exploratory in nature1 or have had a particular focus, such as occupational stress.2,5,15,16,17 The present study was designed to provide policymakers with more comprehensive data which could be used to inform workforce planning in NHSScotland. As far as the authors are aware, this is the first published study of all NHS consultants in Scotland.
There are recruitment and retention difficulties within NHSScotland and the development of a flexible workforce is regarded as a partial solution.18,19,20.21 The complexities of the "old" consultant contract have been widely criticised22 and the need for realistic job plans and career development is recognised.18,20 The "old" consultant contract allows whole-time consultants to undertake limited private practice (with remuneration no higher than 10% of their NHS salary). Those with a part-time contract (including the "maximum part-time" contract), can undertake unlimited private practice. Consultants are entitled to draw their NHS pension from age 60 but can continue working until age 65.1 *
In 2002, consultants in Scotland voted in favour of the new contract,23 albeit by a small majority (59%) and their leaders, theScottish Committee for Hospital Medical Services (SCHMS), agreed to enter into negotiations with the Scottish Executive.24 In 2003, 77% of consultants in the UK agreed in principle to the revised contract. The exact terms and conditions bary between the four UK countries. (www.bma.org.uk/ap.nsf/Content/ CCSCContractComparison, accessed 4 May 2004). In Scotland consultants will work a standard working week of 10 x 4-hour programmed activities [PAs]. PAs worked between 0800 and 2000 will be paid at the basic rate whilst PAs worked outside these times will be counted as three hours instead of four. Restrictions on private practice are limited. For example, consultants who do private work and refuse to work an additional PA where this is offered may find their pay progression adversely affected. Daytime and on-call intensity payments are replaced by on-call availability supplements. The distinction award and discretionary points systems are to be reformed. The present survey was the first phase of a wider study in which similar data were collected from staff and associate specialist doctors and general practitioners. The purpose of the study was to elicit consultants’ views on flexible working and to gather data about current workloads, remuneration levels, sources of job satisfaction and retirement plans. The aim is to repeat these surveys at regular intervals so changes over time can be examined.
Methods
One of the authors (FF) compiled an extensive literature review.24 In March 2001, the Information and Statistics Division (ISD) of the Scottish Executive Health Department provided a list of 3175 consultants in NHSScotland. The research team conducted 14 interviews and four focus groups with purposively selected consultants. The information gathered was used to inform the content of the questionnaire. An initial pilot survey was conducted and the revised questionnaire piloted with a random sample of 56 consultants.
The questionnaire contained open-ended and closed questions. Ten items from the Warr-Cook-Wall job satisfaction scale25 were included. Each scale is rated from one to seven, where one denotes least satisfied and seven denotes most satisfied. On-call intensity payments were used as a proxy measure for level of on-call commitment. A series of attitudinal statements was presented with four response options: strongly agree, agree, disagree and strongly disagree.
In June 2001, the questionnaire plus covering letter and reply paid envelope was mailed to 3088 consultants (ISD duplicate names were excluded as were consultants who had retired or died). One reminder letter, together with another questionnaire, was sent after four weeks.
Quantitative data analysis and statistical tests
Questionnaire responses were matched to ISD demographic data. The Statistical Package for the Social Sciences (SPSS) was used to analyse quantitative data. The X2 test was used to analyse categorical data and the Student’s ttest for continuous data. As a large number of comparisons between different groups were made, a significance level of 1% was accepted (p<0.01). Where data were not normally distributed, the median values were calculated together with the interquartile range (25th percentile and 75th percentile) and corresponding non-parametric tests were used.
Qualitative data
Common themes were identified from the extensive free comments given by respondents. Transcripts were read independently by two researchers to increase the reliability of the free text analysis.
Results
Response rate
The usable response rate was 61%(1793/2923). Those who were on sick leave, maternity leave or were not known at the given address were excluded from the denominator. Denominators used to present percentages may differ a not all respondents answered all questions. Characteristics of respondents were similar to those in the ISD dataset (Table I). Surgery (63%) and laboratory medicine (57%) had lower response rates than the other specialty groups (×2=28.371, 9df, p<0.01). Ethnic minority consultants were less likely to respond than white consultants (47% vs 63%; X 2=21.573, 1df, p<0.01).
Specialty and contract type by gender
Males were more likely than females to hold a whole-time {(73%)[976]) vs (64%)[282]} or maximum part-time contract {(13%)[168] vs (4%)[18], X2=224.05, 3df, p<0.001}. Consultant surgeons were predominantly male {(93%)[284] vs (7%)[20]}. Psychiatry was the most gender-balanced of the specialties {41%[96] were female}.
Current workloads, private work, discretionary
points and distinction awards Tables II and III provide details, by specialty, of daytime hours worked per week and proportions of respondents receiving intensity payments, discretionary points and distinction awards. Male respondents, aged 50 years or less, were more likely to receive discretionary points and distinction awards than females in the same age group but this trend was only statistically significant for those holding ordinary part-time contracts {(63%)[15] vs (26%)[23]; X2=21.9, df=4, p<0.01}. It was not statistically significant for males and females over the age of 50, regardless of contract type (Table III). On average, respondents spent one hour per week on private medical work. Over half (54%)[933] either did not participate in private work or undertook only Category 2* work. Males who held whole-time or maximum parttime contracts were more likely than females with corresponding contracts to participate in any sort of private work {(62%)[591]) vs (43%)[117]; X2=30.29, 1df, p<0.001} and {(94%)[157] vs (72%)[13]; X2=9.32, 1df, p=0.01}. Respondents in surgery (80%)[237] and A&E medicine (79%)[22] were the most likely to work more than five hours per week in private practice.
Consultants’ views about workloads and staffing levels
Many respondents (77%)[1309] felt that their workload had increased as a result of the New Deal, with consultants in some specialties such as oral medicine (45%)[20] and laboratory medicine (57%)[75], being affected to a lesser degree. Almost two-thirds (65%)[1154] of respondents believed that their workloads were unreasonable and unsustainable. Male consultants with whole-time or maximum part-time contracts and working in accident and emergency (82%)[18], obstetrics and gynaecology (76%)[41] or radiology (76%)[68] were more likely to report this than similar respondents in other specialties {X2= 29.231, df=9, p<0.01}. Two-thirds (67%)[1179] of respondents felt that they were unable to provide their desired standards of patient care. Of those working wholeor maximum part-time, females in paediatrics (83%)[14] and radiology (76%)[19], males in psychiatry (83%)[95] and radiology (83%)[75], and both males (76%)[190] and females (73%)[41] in medicine were most likely to feel this to be the case. Almost two-thirds (63%)[1112] of respondents felt that they had insufficient time for outside interests and that their working hours were having a detrimental effect on their family life. The latter was more likely to be felt by males working full-time or maximum part-time in accident and emergency (77%)[17] and obstetrics and gynaecology (76%)[40]. A smaller proportion (44%)[772] of respondents felt that their health was being adversely affected, with no differences found between specialties or by gender.
Many (84%)[1493] believed that some of their work could be undertaken by less qualified staff but 79%[1405] also agreed that there was insufficient staff in their units for this to be possible. Two-thirds (67%)[1191] stated that they did not normally take meal breaks (minimum 30 minutes) during working hours. Females with whole-time {(73%)[204] vs (61%)[583]; X2=14.5, df=1, p<0.001} or ordinary part-time {(80%)[78] vs (50%)[13]; X2=9.9, df=1, p=0.002} contracts were significantly less likely to take meal breaks than males with similar contracts.
Attitudes to change
Many (76%)[1301] respondents disagreed that a shift system for consultants would improve their quality of life and 67%[1126] thought it would be detrimental to the continuity of patient care. However, most would welcome the opportunity to have either an annual developmental appraisal or an annual performance appraisal {(81%)[1424] and (76%)[1336] respectively}.
Annual leave, special leave, study leave
Half (51%)[856] had not taken their full annual leave entitlement. The total number of days not taken in the previous leave year totalled 6135 (equivalent to 28 wholetime consultants). A minority (13%)[222] had not taken 10 days or more. Analysis of respondents’ comments showed that 97%[675/696] cited factors relating to workload/lack of cover as the main reason for not taking their full entitlement. "Going on leave makes work worse immediately before and after - this stress is not worth taking leave. When on leave, if I’m not away, I go in every day - I feel I cannot trust the junior medical staff to cope." [Trauma and Orthopaedic Surgery]
Respondents had taken a median of four days special leave per year. Some consultants felt they could not take their annual leave because they had already taken leave for other reasons. "I have other commitments . . (Royal College of Obstetricians and Gynaecologists) . . and felt I could not take any other time off since my colleagues have to cover." [Obstetrics and Gynaecology] Consultants with whole-time contracts had taken a median of 20 days [range 0-90] study leave in the previous three years, 10 days less than the standard entitlement. The main barriers to participation in continuing professional development [CPD] were felt to be lack of time (87%)[1500] and insufficient clinical cover (75%)[1303]. Fatigue was also a barrier for 46%[780].
Job satisfaction
Analysis of the Warr-Cook-Wall rating scales [median (IQR) presented] showed that respondents were least satisfied with their hours of work [3(2,4)], particularly those with whole-time contracts [3(2,4)], recognition eceived for good work [3(2,5)] and pay [4(2,5)]. Satisfaction appeared greater for freedom to choose their own method of working [5(4,5)], amount of responsibility [5(4,6)], colleagues and fellow workers [5 (5,6)], opportunity to use their abilities [5(4,6)] and variety of work [5(4,6)]. The median (IQR) rating for overall job satisfaction was 5(4,5). Female respondents working full-time were more satisfied [4(3,5)] with pay than male respondents working full-time [4(2,5), Mann Whitney p<0.01]. Younger consultants (50 years and less), male and female, reported less satisfaction [4(2,5)] with pay than older consultants (over 50 years) [4(3,5)], (Mann-Whitney p<0.01). When specialties were compared, dissatisfaction with pay was greatest among surgeons [3(2,5)] and anaesthetists [3(2,4)], Kruskal- Wallis p<0.01).
Consultant psychiatrists were most dissatisfied with their degree of responsibility [5(4,6)] whilst paediatricians were most satisfied [6(5,6)], Kruskal-Wallis p=0.001). Dissatisfaction with variety of work was greatest in psychiatry [5(4,6)], anaesthetics [5(4,6)] and radiology [5(4,6)], (Kruskal-Wallis p<0.01). Overall job satisfaction was lowest in radiology [5(3,5)], accident and emergency [5(3,6)] and psychiatry [5(3,5)]. When asked what they enjoyed least about their job, 1337 espondents provided free text comments, from which a number of themes were identified (Table IV). Similarly, 1333 respondents listed aspects of their job which they most enjoyed (Table V).
Plans to reduce contracted sessions
Only (12.5%)[220] planned to alter their number of contracted sessions. Of all those who planned to make a change, the majority (90%)[184] intended to make a reduction. The median (IQR) planned reduction was one [(1,1)] session. Reasons for wishing to make a reduction are presented in Table VI. With respect to gender and contract type, females working whole-time were more likely to wish to alter their sessions than males working wholetime {(17%)[46] vs (11%)[101];X2=15.4, df=2, p<0.01]}.
Plans to retire
The mean (sd) planned retirement age was 60(3) years with no significant difference between males and females (of psychiatrists appointed prior to 1995, 34% planned to retire at age 55 or earlier). Almost one quarter (23%)[389] described their plans as definite while a further 70%[1205] described them as "very likely " or "quite likely". However, consultants did identify a number of factors which might induce them to delay their retirement plans: reduced workload/work intensity (50%)[541], improved pay (14%)[151], protected pension (12%)[129] or interest/ job satisfaction/teaching (13%)[141]. One-tenth (10%)[108] thought they might have to continue working for financial reasons.
Home/work balance
Male respondents were more likely to have a long-term partner or spouse than female respondents {(94%)[1233] vs (84%)[361], X2=39.194, df=1, p<0.01}. Males were also more likely to have children and/or young adults living at home {(70%)[950] vs (61%)[271], X2=12.985, df=1, p<0.01}. Female consultants were more likely than male consultants to have modified their working hours {(29%)[94] vs (12%)[128], X2=54.769, df=1, p<0.001} or their career aspirations {(30%)[97] vs (13%) [137], X2 =53.230, df=1, p<0.001} to accommodate their partner’s career. However, the partners of male respondents were more likely to have done so than the partners of female respondents {(57%)[611] vs (31%)[101]} – working hours} and {(57%)[610] vs (31%)[101] – career aspirations}. This difference remained for all types of contracts. More than half (55%)[666] of respondents’ partners who were in paid employment worked in a health-related occupation. Of these, male respondents’ partners were more likely to have modified their working hours {(61%)[324] vs (17%)[22]; X2=82.927, df=1, p<0.001} or career aspirations {(58%) [306] vs (20%) [26]; X2=60.316, df =1, p<0.001} than female respondents’ partners.
Discussion
This study provides ample evidence that consultants in NHSScotland perceive themselves to be carrying heavy workloads to the detriment of their family lives, their own health and standards of patient care. Consultants with whole-time or maximum part-time contract were more likely to report difficulties than those with ordinary part-time contracts. For example, males working whole-time or maximum part-time were more likely to report that their workloads were unreasonable and unsustainable, particularly if they worked in accident and emergency, obstetrics and gynaecology or radiology. However, female respondents were less likely to take meal breaks during working hours than male respondents, irrespective of type of contract. Around half of all respondents had not taken their full annual leave entitlement and the median days study leave was 10 days less than the standard entitlement over a three-year period.
Analysis of the Warr-Cook-Wall job satisfaction rating scales showed that dissatisfaction was greatest for hours of work (particularly for those with whole-time contracts), recognition received for good work and pay. Younger consultants were less satisfied with pay than older consultants whilst females who worked full-time were more satisfied with pay than males who worked full-time. The qualitative data revealed that patient care and/or patient contact continued to provide considerable job satisfaction. The average planned retirement age was 60 years, with 23% describing their plans as definite and 70% as quite or very likely. When asked what might induce them to postpone retirement, 50% cited reduced workload/work intensity.
With respect to private work, 54% either did none or undertook only Category 2 work. Almost one-fifth of those who did participate spent more than five hours per week on such work with surgeons most likely to do so. Interestingly, female respondents with a maximum part-time contractwere less likely to participate in non-NHS medical work than males with the same contract. Although the maximumpart-time contract is usually associated with consultants who wish to undertake more private practice, it would appear that women consultants are choosing it for different reasons. Females working whole-time were also more likely to wish to alter their sessions than their male counterparts. The new consultant contract recommends an increase in salary together with a 40-hour working week, including worked on-call duties. This should address two of the main sources of dissatisfaction expressed by consultants in this study. However, the average daytime hours worked per week (excluding on-call) currently exceeds 40 hours in all specialties. This study therefore provides further evidence of the urgent need to address staffing deficiencies in NHSScotland if current standards of patient care are to be maintained. Otherwise, consultants may continue to forego part of their leave entitlement in order to maintain an adequate level of service.
Many (84%) consultants believed that some of their work could be delegated to someone less qualified but 79% agreed that there were insufficient staff to make this possible. Consequently, recruitment and retention of, plus appropriate training for, nurses, allied health professionals and administrative staff are vitally important. When asked what they least liked about their job, around one-third reported difficult relationships with health service managers. The revised consultant contract is designed to allay consultants' concerns about increased managerial control. Respondents indicated that a gradual reduction in workload towards retirement age together with protected pension rights would possibly induce them to continue working beyond their planned retirement age. It is important therefore that opportunities for phased retirement are made available to consultants.
Female respondents were more likely than male respondents to have changed their working hours or career aspirations to accommodate their partner’s career. The partners of male consultants were also more likely to have made similar accommodations. As more women doctors enter the consultant grade, the whole-time equivalent is likely to decrease if women continue to give priority to their partners’ careers. Interestingly, more than half of respondents’ partners who were in paid employment also worked in a health-related occupation. Consequently, whilst NHSScotland may benefit from the long hours currently worked by male consultants, it may be losing potential hours of work by their female partners. A better work/life balance would benefit not only consultants themselves but would also improve their family life and perhaps allow some partners to commit more time to their own careers. NHS Scotland could ultimately benefit from this.
Consultants in Scotland have twice voted in favour of the new consultant contract. Increased pay and a standard 40-hour working week, including worked on-call and working lunches, should address the two main sources of dissatisfaction amongst consultants in Scotland. However,the implementation of the new contract will only be successful if staff shortages and information technology deficiencies are addressed. Otherwise, consultants may continue to neglect their families, their health and their professional development in order to provide patient care. Reduced workloads may help to persuade some consultants to work beyond the age of 60.
The main strength of this study was the fact that it was the first comprehensive study of consultants in Scotland. The main limitations included reliance on self-reported hours of work and the use of on-call intensity payments as a proxy measure for on-call. The authors believe that this study provides a good benchmark for future studies of consultants. In particular, it will enable an assessment of the impact of the new contract on consultants in Scotland.
ACKNOWLEDGEMENTS:
Our thanks go to the consultants in Scotland who responded to the survey and to the Steering Group members. Joyce Walker provided excellent secretarial support. Catriona Walker and Avril McCreadie diligently entered all the data.
Funding: Scottish Council for Postgraduate Medical and Dental Education (now NHS Education for Scotland) Research and Development Grant Competing
Interests: Professor Gillian Needham is an honorary consultant radiologist and was one of the survey respondents
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