Junior doctors in the United Kingdom and Ireland are qualified medical practitioners who are working whilst engaged in postgraduate training to become a consultant or a GP. The period of being a junior doctor starts when they qualify as a medical practitioner following graduation with Bachelor of Medicine, Bachelor of Surgery degrees, and culminates in a post as a Consultant, a General Practitioner (GP), or some other non-training post, such as a Staff grade or Associate Specialist post.
The term junior doctor now incorporates the grades of Foundation doctor, Specialty registrar; and prior to 2007 included the grades of Pre-registration house officer, Senior house officer and Specialist registrar. During this time junior doctors will do postgraduate examinations to become members of a Medical royal college relevant to the specialty they are practicing, for example Membership of the Royal College of Physicians for doctors specialising in Internal medicine, Membership of the Royal College of Surgeons for doctors specialising in surgery or Membership of the Royal College of General Practitioners for doctors specialising in family medicine. Doctors typically may be junior doctors for 5–15 years, and this may be extended by doing research towards a higher degree, for example towards a Doctor of Philosophy or Doctor of Medicine degree. In England there are around 53,000 junior doctors. The term non-consultant hospital doctor or NCHD also has currency in the Republic of Ireland.
In Europe and the US there has been some reduction of the working hours of doctors who are in postgraduate training, in line with recommendations and legislation aimed at improving patient safety and doctors’ working conditions. In 1991 the government, the NHS and the British Medical Association agreed a package of measures on working hours, pay and conditions which was called the New Deal for Junior Doctors. The Doctors' duty hours, which were felt to be excessive, were reduced to a maximum average of 56 hours actual work and 72 hours on call of duty per week, although the change was not enforced until 1 December 2000. The European Working Time Directive (EWTD) sets out minimum health and safety requirements for the organisation of working time. The EWTD required the average working week to fall to 48 hours or less by 2009.
The shortening of junior doctors' working hours had implications for how training programmes are organised, especially for specialties such as surgery where there was a tradition of maximising the hours of experience. Most studies that have looked at a reduction of junior doctors working hours have found either a beneficial or neutral impact in terms of measures of patient safety, clinical outcomes and postgraduate training.
The reduction in number of hours worked by junior doctors is one of the factors leading to blurring distinctions between them and other clinical professions such as nurse practitioners who also perform complex tasks. Shorter duty shifts involve close teamwork across professions and effective handovers. Medicine is becoming more specialised, cross-cover between specialties can occur at night and during the day and evening. Most patient care and learning under supervision takes place in the day.
Modernising Medical Careers
In 2005, Modernising Medical Careers saw significant changes to postgraduate medical training. A two-year Foundation Programme was introduced for newly-qualified doctors, the number of years of postgraduate training changed in some specialties and it was doctors were needing to decide which specialty to follow sooner after graduation.
There have been recent initiatives to engage junior doctors in NHS leadership; junior doctors are seen as essential to the drives to achieve efficiency savings in the NHS.
|Old system||New system (Modernising Medical Careers)|
|Year 1:||Pre-registration house officer (PRHO) - one year||Foundation Doctor (FY1 and FY2) - 2 years|
|Year 2:||Senior house officer (SHO)
a minimum of two years, although often more
|Year 3:||Specialty Registrar (SpR)
in a hospital speciality:
minimum six years
|Specialty Registrar (GPST)
in general practice:
|Year 4:||Specialist registrar
four to six years
|GP registrar- one year|
|Year 5:||General practitioner
total time in training: 4 years
|Years 6-8:||General practitioner
total time in training:
total time in training:
minimum 7-9 years
total time in training:
minimum 8 years
|Optional||Training may be extended by pursuing
medical research (usually two-three years),
usually with clinical duties as well
|Training is competency based, times shown are a minimum.
Training may be extended by obtaining an Academic Clinical
Fellowship for research or by dual certification in another speciality.
Pay and conditions
The NHS Careers web site states:
|“||As a doctor in training you’ll earn a basic salary plus bonus if you work more than 40 hours a week and/or work outside the hours of 7am – 7pm Monday to Friday.
In the most junior hospital trainee post of Foundation year 1 your basic starting salary is £22,636. This increases in Foundation year 2 to £28,076.
If you’re a doctor in specialist training your basic starting salary is £30,002. If you are asked in your contract to work more than 40 hours a week and/or to work outside 7am – 7pm Monday to Friday, you will receive an additional bonus which will normally be between 20% and 50% of the basic salary. This bonus is based on the extra hours that you work above a 40 hour normal working week.
Since 2007 junior doctors have been receiving below inflation salary rises. The independent Review Body on Doctors' and Dentists' Remuneration (DDRB) takes evidence from a range of sources and makes recommendations around pay; in 2015 they recommended a 1% pay increase. In 2005, the average starting salary for a medical graduate was £32,086.
In an inflationary environment all wage earners including doctors may find the buying power of their income becomes less, some describe this as a real terms cut in pay of 15% between 2007-2014, where the word cut does not actually indicate a wage reduction.<
The basic starting salary of a foundation doctor is £22,636 although research conducted in December 2014 showed that almost a third of graduate programmes at Britain's best known and leading employers now pay more than £35,000.
Doctors pay professional annual fees to maintain registration with the General Medical Council and medical indemnity cover. Junior doctors also incur costs associated with training courses, preparing for and sitting exams and college membership; training can be associated with £420-£3000 of professional fees annually depending on stage of training and level of income. Students embarking on a medical degrees can now expect to pay £40,000 on university tuition fees alone. Student loans are available to meet these costs, with repayment starting as soon as individuals begin working as a junior doctor.
Changes to working patterns of doctors meant there was no longer a requirement for first year junior doctors to be resident and from 2008 free accommodation was no longer provided by employers. The British Medical Association, claimed this amounted to a £4,800 annual pay cut for those who may have previously lived at the hospital rather than independently but the numbers of doctors involved is not yet clear. Ann Keen, Labour Parliamentary Under-Secretary for Health Services, stated "The provision of free accommodation for foundation year 1 doctors who are on call at night, is dependent on the contract of employment of the junior doctor, which is for agreement locally. The Junior Doctors Terms and Conditions of Service continue to provide that if a doctor is contractually required to live in hospital accommodation no charges should be made for the accommodation provided."
The NHS Careers web site states:
|“||Doctors in the specialty doctor grade earn a basic salary of between £37,176 and £69,325.
Consultants can earn a basic salary of between £75,249 and £101,451 per year, dependent on length of service. Local and national clinical excellence awards may be awarded subject to meeting the necessary criteria.
Many general practitioners (GPs) are self employed and hold contracts, either on their own or as part of a Clinical Commissioning Group (CCG). The profit of GPs varies according to the services they provide for their patients and the way they choose to provide these services.
Salaried GPs who are part of a CCG earn between £54,863 to £82,789 dependent on, among other factors, length of service and experience.
Junior doctors may pay into the NHS Pension Scheme which from April 2015 has been a Career Average Revalued Earnings (CARE) scheme. The 2015 scheme involves paying towards a pension which will be based on the average of a member's pensionable earnings throughout their whole career, with a revaluation of active members benefits in line with the Consumer price index plus 1.5 per cent per annum. The 1995/2008 scheme is closed to new entrants.
Junior doctors and patient mortality
The period in August where there was a large changeover of hospital staff has sometimes been dubbed the "killing season" (due to a perception that there is an associated rise in the number of patient deaths). In 2009 research looking at emergency admissions to hospitals in England established that a small but statistically significant increase in patient mortality was occurring during August. The limited data was collected retrospectively over a 8 year period, comparing two week-long blocks (one week prior to commencement, one week post commencement). The methodology meant that drawing firm conclusions was unwise with correlation not implying causation. In the month when junior doctors start working - when other factors are adjusted for patients had a 6% increase in mortality. For patients admitted as an emergency who were not requiring surgery or suffering from cancer, the mortality rate increased by 7.86%.
Other concerns have been raised regarding mortality following admission to hospital at a weekend. A research paper published in 2012, looked retrospectively at data from 2009; the study observed an increase in 30 day mortality for people admitted to hospital on Saturday and Sunday, compared to mid-week days. The risk of dying in a hospital on Saturday or Sunday was actually less than on a weekday. The data in the study did not allow the authors to describe the cause of this so-called weekend effect. Subsequently there has been some speculation around whether the availability of consultants was a factor.
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