Doctors ‘avoiding hard work’ in A&E

David Caesar says there's been a shift in ethos. Picture: Greg Macvean
David Caesar says there's been a shift in ethos. Picture: Greg Macvean
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A LEADING health figure has claimed essential junior doctors are shunning posts in A&E to “avoid hard work”.

The claim from David Caesar, clinical director for emergency medicine at NHS Lothian, that young life-savers are lazy has thrown the harsh working conditions they face again under the microscope.

He says a shortage of junior doctors taking up senior posts in emergency departments is because they want an easier working life.

Antisocial hours, long shifts and frequent weekend work have led to more than half of fourth-year doctors, who trained in emergency medicine, to turn their backs on the once sought-after positions.

The snub has led to a national recruitment crisis, with just one in five A&E departments now deemed adequately staffed, resulting in calls to make the essential, life-saving posts more attractive.

Addressing an NHS board meeting, Dr Caesar said less than 40 per cent of qualified trainees are taking up the positions at NHS Lothian, and put the failure to attract people down to a shift in ethos. “The medicine hasn’t changed, it is still the best medicine you can practice in my opinion,” he said. “Culturally, people don’t want to work hard any more. You get a lot of medical students making choices based on lifestyle and work-life balance.

“At the moment we have an increasing length to retirement, it’s a very difficult thing to get people to buy into.

“If we have an increase in recruitment, there’s still a three-year-long period until they get to the level of an experienced decision maker.

“We are doing better than most to attract people to the region but it’s still going to take a bit of time.”

The situation has led the president of the Royal College of Emergency Medicine to call for better pay and conditions for doctors working unsociable hours. Dr Clifford Mann said changing emergency doctors’ contracts might encourage trainees who are opting out of A&E training in favour of less demanding and stressful specialities.

At present, A&E doctors’ hourly pay is about 25 per cent more for overnight and weekend shifts. But Dr Mann said salaries should be changed so doctors working shifts after midnight get twice the hourly rate, which would allow them to take more time off while earning a similar salary.

He added there were no problems recruiting doctors into the initial stages of emergency medicine training and the problem arose when it came to the fourth year.

He said: “We have to recognise the fact that if you are expecting people to work a larger proportion of their working day out of hours, that’s 
evenings, nights and weekends, there needs to be some amendment to the terms and conditions to make that an attractive option.”

Former health secretary Malcolm Chisholm MSP said understaffing was a long-standing problem, in part caused by a recent EU directive on working hours and rising numbers of people going into A&E.

“It is not just a problem in Edinburgh but across Scotland,” he said.

“They need to recruit more people and in these situations they are going to have to give incentives.

“If there are real problems in a speciality then it may be that they have to offer bonus payments to encourage recruitment.”

One GP – who did not wish to be named – said her recent time as a junior doctor at a busy A&E ward was “hellish”. She said: “People dying on you; drunks spitting at you, touching you up and throwing up on you. No thanks. Long hours. It was hell on earth. It’s nothing to do with being lazy – I just wanted to go somewhere I was better appreciated.”

Scottish Conservative health spokesman Jackson Carlaw said there had been plenty of time to plan for the eventuality. He said: “This may well be the case, and hardly surprising given the scores of hours student 
doctors traditionally put in each week.

“Some time ago EU rules were brought in dictating a 48-hour working week and, whether you agree with that or not, it’s been known for some time. As a result, health boards and the Scottish Government should have been able to plan accordingly.

“Young, hungry doctors willing to work all the hours under the sun should be seen as a bonus, not the glue to hold the health service together.”

Margaret Watt, of Scotland Patients Association, said long hours and irregular shift patterns are what doctors sign up for. She said: “A&E is not a different environment to other industries where staff have to work seven days a week. It can’t be avoided. But there does seem to be a problem getting staff into A&E and it’s something that needs to be looked at.

“We need to make sure staff are happy. But there’s nothing we can do about the hours, these are the hours we need in A&E.”

A spokesman for the union BMA, said workforce planning was essential as the NHS enters a period of 
sustained financial constraint.

‘It takes a special kind of person’

Lynn McDowall, Edinburgh and Lothians officer for the Royal College of Nursing, outlines what it takes to work in a busy accident department:

“Working in A&E requires a high level of skills simply because you don’t know what is going to come in through the door.

“It’s very different to working on a ward, for example, that specialises in care for the elderly.

“In those circumstances you would know that everyone coming on to the ward is going to be for reasons to do with elderly care.

“In A&E there is no way of knowing – it could be people coming in with breathing difficulties, suffering cardiac arrest, patients involved in serious accidents, or drug and alcohol-related admissions.

“The staff have to cater for whoever comes through the door and they need additional training so it takes extra time.

“Other departments will be easier to work in because they will not have all of the added pressures A&E staff are working under.

“Government targets mean they are asked to get 98 per cent of patients treated and admitted or discharged within four hours.

“This is nigh-on impossible to do because there is often a problem at the other end – for example, where there are no beds for patients to go to, or because of the sheer number of patients coming in.

“I think if you were to ask most A&E staff they will say targets are not a bad thing and that they will do their best to meet them, but it is very difficult for them to achieve them because of the nature of their work.

“You wouldn’t have that problem if you worked on another ward as there would be no requirement to move patients on after four hours.

“Instead, you walk on to a ward that has 28 beds and know that is what you had to deal with that day.

“A&E is a difficult place to work because it is unpredictable, but one thing almost guaranteed is that it will be challenging.

“It is always busy on a Monday as people have put off coming with something until after the weekend.

“I think it does take a special kind of person.

“A lot of years ago A&E was seen as the place that you wanted to work, it was glamorous and the department that was always on telly with Casualty and Holby City.

“It is always shown as a fantastic place to work but you are on the go all the time.

“It is suited to some people and not to others. The pressure is never off, whatever the hour. On some wards you might expect it to be quieter at night when patients have gone to bed but with A&E it is 24/7. There is no change in activity, regardless of the time of day. There are definitely easier jobs for people to do.”


The European Working Time Directive is an EU initiative designed to prevent employers requiring their staff to work excessively long hours, with implications for health and safety.

It limits doctors in training to a maximum 48-hour week, averaged over a six-month period and lays down minimum requirements in relation to working hours, rest periods and annual leave.

It was implemented in 2009 when there were concerns by unions it would harm the quality of training and the Royal College of Surgeons saying it put lives at risk.

Doctors are able to work longer hours by signing an opt-out clause.