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Royal College of Physicians

News & Views

Large variations in medical cover in hospitals at night

Research carried out by the Royal College of Physicians (RCP) has identified large variations in the provision of medical cover at night, with some doctors being responsible for up to 400 patients.

The study, to be published later in the year in Clinical Medicine, examined the makeup of clinical teams in hospitals in England and Wales and the number of patients for which each team was responsible. It found that, at night, doctors were responsible for an average of 61 patients, but the range was from 1 to 400.

The seniority of doctor in charge of a ward also varied considerably; 63 teams reported that, on the night the survey was carried out, the most senior medical cover was a junior doctor in their first 2 years of training. Consultants were involved in the direct delivery of overnight care in only 6% of teams.

Day cover on the ward ranged between 2 and 65 patients per junior doctor, with the highest ratio per doctor in Wales and the lowest in London. This reflects a much higher number of trainees in the region (in 2008 there were 1,135 specialist training posts in London compared with 146 in Wales). The average number of patients per doctor also varied considerably between specialties.

Other key findings identified possible problems with junior doctor welfare and vacancy rates, including:

  • 58% of consultants reporting an increase in sickness rates of juniors under them compared with before the introduction of EWTD-compliant rotas
  • highest sickness rates in second year trainees, possibly reflecting a loss of team working and sense of belonging in doctors a year into their training
  • vacancy rates ranging from 1% of foundation level trainees (the first two years after qualification) and 8.6% of specialist trainees.

As it is not mandatory to report sickness rates, this survey is the first to get independent evidence of current rates for junior doctors across England and Wales, and show that they are higher than a recent survey by the NHS Information Centre suggests.

Vacancy rates are also notably higher than would be expected considering official figures, especially for specialist trainees. This may be because trainees taking time out (for example to do a research degree) are not counted in official figures, despite their absence from the ward needing long-term locum cover. Vacancies have both direct and indirect effects on service provision and potentially patient safety. Rota gaps are often hard to fill with locum staff and there are significant concerns as to the safety of some locum doctors.

Dr Andrew Goddard, director of RCP’s Medical Workforce Unit, commented, “The very low number of doctors per patient at night in some hospitals raises serious concerns for patient safety and there are also worrying reports of very junior doctors being left unsupported, which urgently require further investigation. In the daytime, care for many patients is carried out by junior doctors, which limits their time shadowing more senior doctors and improving their knowledge and skills.

The 48-hour week was brought in to improve the wellbeing of doctors, and by extension prevent mistakes in patient care. The apparent rise in sickness rates of junior doctors since the introduction of the European Working Time Directive highlights the additional stresses that are being put upon trainees by new rotas. Far from benefiting their welfare, the poor implementation of the directive means that juniors are missing out on crucial support and valuable training opportunities, and patient care is being spread too thinly.


  1. This study will be the largest set of data on patient–doctor ratios in the UK, as well as the first independent assessment of sickness and vacancy rates in the training grades.
  2. The anonymous survey was sent to all consultant physicians in England and Wales (as registered with the Royal College of Physicians of London) and asked them to record the membership of their team and number of patients for which their team was responsible, at 11 am and 11 pm on a specific date in November, in order to create a snapshot of staffing levels.
  3. Other data requested included the size and location of the hospital (by region) and the location of each member of the team (for example on the ward/on sick leave/vacant post).
  4. Data was available on 887 hospital teams at 11 am, including 4,004 junior doctors caring for 18,854 medical patients, and on 670 teams at 11 pm, including 2,263 junior doctors caring for 97,561 medical patients.
  5. The distribution of responses from different Strategic Health Authorities (SHAs) was representative of the size of each SHA, as were the responses for the individual medical specialties.
  6. ‘Day cover on the ward’ excludes the grade of Specialist Registrars (SpR), as most ward teams are run without SpRs most of the week.
  7. The NHS Information Centre study referred to is: Sickness absence rates in the NHS: April – June 2009. London: NHS IC, 2009
  8. A PDF of the abstract for the report will be available on the RCP website from Wednesday, 21 April 2010.

Published on: April 21, 2010

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