The task of standardising on-call rosters and ensuring sustainability

Paul Mulholland reports on continuing concerns regarding the variability and onerousness of on-call rosters

In July 2022, the Chair of the consultant applications advisory committee (CAAC), Prof Áine Carroll, wrote to HSE National Director of Human Resources, Ms Anne Marie Hoey, about on-call rosters.

Prof Carroll stated that a general discussion arose during a CAAC meeting earlier that month about the “noticeable variability” in on-call rosters both across and within specialties and hospitals.

The CAAC had previously discussed the issue at its meeting in May.

Following the May meeting, the committee was told by the HSE that participation in on-call rosters was a contractual requirement as set out in the consultant contract 2008 and reflected the needs of the employer in local service delivery.

“Notwithstanding that CAAC’s remit lies in the development of consultant services throughout the country, the CAAC has asked that I write to you regarding the variability in on-call rosters,” according to Prof Carroll’s letter, which was obtained by the Medical Independent (MI) under Freedom of Information law.

“It requests that it be shared with relevant stakeholders (eg, acute hospitals, postgraduate training bodies) to provide/develop guidance on specialty on-call rosters which support staff whilst remaining responsive to the needs of the public availing of health services.”

When asked by MI about the issue of roster variability, a spokesperson for the HSE said: “Standardisation of consultant on-call rosters is influenced by specialty, patient profile, and the number of consultants participating on a particular roster.”

At the September meeting of the CAAC, the issue was the subject of a further discussion in relation to integrated and enhanced care posts. According to the minutes, the clarifications provided by the HSE were noted. A total of five consultant posts in geriatric medicine were approved, subject to clarification with regard to pro-rota on-call cover at the acute sites.

“It was agreed that with on-call being an operational matter for each site and service, [Clinical Programme Leads and National Clinical Advisor and Group Leads] would be best placed to provide guidance when reviewing the application,” the minutes stated.

“It was further agreed that where on-call was on a pro-rata basis, this would clearly be set in terms of cover.”

Concerns

Chair of the IMO consultant committee Prof Matthew Sadlier told MI the Organisation “specifically pursued” the problem of onerous rosters and variability within rosters during the recent consultant contract negotiations.

According to Prof Sadlier, the IMO also argued that “B and C factor arrangements” within the 2008 contract were not sufficient to address the issue.

The B factor payment is to compensate consultants for their liability to be on-call and is tiered for those on more onerous rotas, while the C factor payment is for specific call-outs.

“Indeed, given that there is an annual cap on C factor payments, there is an active disincentive for managers to move towards more sustainable on-call rotas,” Prof Sadlier told MI.

“We are of the view that any expansion in the consultant workforce should, in the first instance, address and eliminate onerous on-call commitments, which are bad for consultants and bad for patients.”

HSE document

To coincide with the new Sláintecare consultant contract, the HSE has produced a document entitled ‘Principles of Rostering Consultants’.

The document states: “Whether the daily, weekly or monthly rota is seen as satisfactory or onerous influences the recruitment and retention of consultants. Whether work commitments may be seen as interfering with social life, personal development and hobbies, outings with friends and sports, family life is significant. Providing sufficient notice and flexibility is key to the successful rota and our shared goal of attracting staff to these roles.”

In terms of work scheduling, including core working hours, any on-call commitments and/or additional scheduled commitments, the aim is to achieve an “equitable distribution of schedules so far as is reasonably practicable”.

“This will include a reasonable and fair distribution of work at weekends, on public holidays and in late evenings,” according to the document.

In order to maximise capacity, the HSE plans for consultants to move towards a six-day working week, as resources allow, which is enabled by the new contract.

This move will be “incremental” and its implementation will be dependent upon the recruitment of a sufficient number of consultants under the 2023 contract.

Consultants will continue to provide on-call cover outside of their core weekly working hours and any required additional hours. Both B and C factor arrangements are to continue under the new contract, though remuneration has increased.

“Having more medical staff on site over a longer number of hours each day will replace some of the on-call duties undertaken by consultants heretofore,” according to the document.

However, with the recent IMO ballot rejecting the new contract and a survey from the IHCA highlighting the significant concerns of consultants, it is far from certain whether the new working arrangements envisaged by health management will become a reality, particularly in the short-term.