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Leadership: Learning On The Job

How the 2016 Junior Doctor Contract is helping us lead change in the NHS

As Foundation Year 1 (FY1) doctors, we didn’t think we could have an impact in the NHS. Leading change was only for managers and consultants. We were bottom of the hierarchy – tiny cogs in a huge machine. And yet… in just a few months we had redesigned working hours, achieved back-payments and increased salaries for FY1s at a London hospital.

We started with a familiar story: FY1s working in surgery never left on time. Despite the rota stating a 08:00-16:00 shift, we found ourselves arriving half an hour early to prepare for ward rounds, and leaving half an hour late due to handover. An extra hour a day; an extra 28 days a year. The rota simply didn’t reflect the hours we worked – and neither did our pay.  We thought we should do something about this.

First we figured out exactly how many hours we were currently being paid to work. As you may be aware, your work schedule determines your pay and how many hours you work; whilst your rota defines exactly when those hours fall. We compared FY1 rotas and work schedules, and were surprised by what we found:

  1. All the FY1s were rostered to work more hours than they were paid for. The average difference was 2¼ hrs/wk amounting to an underpayment of £1,499.25 per annum.(1)

  2. Annual leave and bank holiday allowances had been incorrectly omitted from the salary calculations in all of the work schedules.

  3. Incredibly, a fifth of work schedules had hours-templates containing a week of zero days timetabled to occur after the placement had finished. These “virtual” zero days artificially lowered the average weekly hours worked and thus unfairly decreased the salary.

  4. Individual FY1s were paid to work different hours (range 42 hrs/wk to 46 hrs/wk) and consequently were paid different amounts (range £28,772 per annum to £31,357 per annum).

  5. On average, FY1s were contracted to work 44½ hrs/wk  – so there was scope to increase shift lengths (maximum 48 hrs/wk).

In short: we were all working different hours, and all being underpaid. We shared our findings with the Junior Doctors’ Forum (JDF), the Guardian Of Safe Working Hours and Human Resources, and a back payment for the extra hours was issued.

However, we needed to find a more sustainable solution. We therefore consulted stakeholders, and agreed realistic shift start and finish times. We then modelled and costed new work schedules. Following many discussions and consultations, these new work schedules – and their corresponding rotas – were implemented. Now all FY1s work the same hours and are paid fairly.

If We Can Do It, So Can You

We are two foundation year doctors with no prior healthcare leadership experience. When we unwittingly came across these issues, we wanted to be part of the solution.

To continue the practice of ‘see one, do one, teach one’, we want to share some of the things that we learnt along the way…

Know your facts

If you want to lead a team and bring about real change, you need to be confident about the details of your subject matter. Not knowing your material is one of the quickest ways to lose your credibility and halt progress- once it’s gone, it’s very difficult to get back. We read the contract (actually not as dull as it sounds!) to ensure our proposed changes would work.

Consult everyone

We can’t overstate the importance of identifying your stakeholders and involving them early. At the start of our project, we thought FY1s would be the only people affected by our rota changes, but this was far from the reality. Junior doctors wanted fair pay and safe hours; Human Resources sought generic and compliant work schedules; and budget holders were concerned about the financial implications of our suggestions. Stakeholder engagement ensures different perspectives and priorities are taken into account, and helps achieve the best and most sustainable solution.

Communicate clearly (ideally in person)

Clear and open communication is vital for progress. One of the most frustrating stages of our project involved slow and often slightly confusing emails between the parties involved. Face to face conversations are often faster and less ambiguous. They were the only way we were able to make real progress.

Demonstrate how the solution would work

Once you have identified your actions, you need to deliver. Creating a model of the new work schedules and their costs was the action that showed the stakeholders we were serious about our proposal.

Use the options available to you

The 2016 Junior Doctor Contract provides many opportunities to lead change. The creation of the Junior Doctors’ Forum, work schedule reviews and exception reporting have all empowered junior doctors. Make the most of these options- you may be surprised how effective they can be at engineering change.

Seek out opportunities, knowledge and mentorship

Seek opportunities to develop yourself and your leadership further. The mentoring and coaching we received on our project challenged us, and pushed us to take our work one step further. That support gave us the confidence to introduce a teaching programme (2), publish articles and present our work nationally and internationally.


Leadership is not about a title or designation. You don’t need CV points, courses or contacts. You just need a clear vision, people who are willing, and the ability to learn from your mistakes. No matter how junior you are, you can have an impact. You can change the NHS.

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