Doctor fatigue: Are there lessons to be learnt from the aviation industry?

Posed by model. Credit: Getty/FamVeld

By Daniel Pye

NHS staff are putting themselves and their patients at risk because they are working when extremely tired, the Health Services Safety Investigations Body has warned. Doctors.net.uk has looked at the existing guidelines for medical staff and compared with the aviation industry to see if any lessons can be learnt about how to manage the issue.

“Do I have the energy or the brain space or the mental space to even make a life changing decision for a patient at this point?”

Those are the words of one resident doctor, who told researchers at the HSSIB that after 3 days of doing 12-hour night shifts “it’s dangerous from 2am onwards”.

The HSSIB report, The impact of staff fatigue on patient safety, found that excessive workloads, long shifts and inadequate breaks are among the factors contributing to the problem.

Saskia Fursland, senior safety investigator at the HSSIB, said: “Fatigue is more than just being tired – it can significantly impair decision-making, motor skills and alertness.

“We must move away from viewing fatigue as an individual issue and putting the onus on personal responsibility and instead treat it as a system-level risk that deserves urgent attention.”

In 2016, Doctors.net.uk ran a survey, in which 1,135 doctors participated. Four in ten (41%) said that they had dozed while driving.

The survey was conducted a year after the death of trainee anaesthetist Dr Ronak Patel.

Dr Patel died while driving to his home in Suffolk after working 3 long night shifts. The inquest heard that he was trying to stay awake by singing to his wife on a hands-free mobile phone and concluded the most likely explanation for the accident was that Dr Patel had fallen asleep.

Nearly a decade on, doctor exhaustion is still an issue, and the risks it poses need to be better understood, according to the HSSIB.

Shift-working and long commutes

In March 2024, resident doctor James Celaire was given a 9-month suspension by the General Medical Council after he was convicted of four counts of causing serious injury by dangerous driving at Bradford Crown Court and handed a 28-month sentence.

The Medical Practitioners Tribunal Service documents state he had worked a 12-hour night shift from 8pm to 8am and had also worked nights the week before.

In the HSSIB report, some staff reported commutes of up to 90 minutes – which further extended their day.

Staff in training programmes, such as resident doctors, were particularly vulnerable as they may have to travel a long way for placements. One staff member said they could “hardly keep [their] eyes open” while driving home after a long commute.

Clinicians also reported working 3 or 4 night shifts, and then not given adequate time off before doing day shifts for the rest of the week.

The report also states that in many clinical areas doctors would work on-call shifts, often immediately after their normal day shift.

So what are the existing rules, regulations and guidance?

In 1998, the European Working Time Directive (EWTD) was brought into UK law as Working Time Regulations, and applied to consultants and career grade staff. In 2004, EWTD was extended to cover resident doctors.

It does not apply to self-employed workers, such as GP partners.

Unless the doctor opts out, they are limited to working 48 hours per week over 26 weeks, with a period of 11 hours continuous rest a day, a day off each week, or 2 days off in each fortnight and a 20-minute rest break every 6 hours.

The legislation states “a night worker’s normal hours of work in any reference period which is applicable in his case shall not exceed an average of eight hours for each 24 hours” however the BMA says that resident doctors are “unlikely to be classified as night workers”.

Working Time Regulations define night workers who “as a normal course” work at least 3 hours of their daily working time during the night.

According to the Royal College of Surgeons (RCoS), EWTD does not cover on-call shifts from home, but only the time spent attending to patients.

For resident doctors on a 2016 contract, the BMA states [pdf] that they should not work more than four shifts where at least 3 hours are between 11pm and 6am, and after this type of shift the doctor must be rostered for a minimum of 46 hours’ rest.

The BMA guidelines also state that when a doctor tells their employer they feel unable to travel home because of tiredness “where possible your employer should provide an appropriate place where you can sleep, without charge”.

“When you’re required to work overnight on a resident on-call working pattern, you should be given overnight accommodation for the resident on-call duty period without charge,” it adds.

It also says that the employer “must cover the cost of alternative arrangements for your travel home” if an appropriate rest facility cannot be provided, and reasonable expenses for the doctor to return to work to begin their next shift or collect their vehicle.

'Resident doctors don't want to miss a case'

The BMA also has a Fatigue and Facilities charter [pdf] which employers can sign up to.

This includes pledges such as using forward-rotating roster patterns to minimise frequent transitions between day and night shifts, supporting ‘bleep filtering’ and policies to enable consistent breaks for hospital staff at night and ensuring rosters and staffing numbers are sufficient to allow safe cover if doctors are unexpectantly absent.

It also advocates for an “easily accessible mess” with appropriate rest areas 24 hours a day, 7 days a week, and lounge, office, kitchen, changing and storage areas for staff where appropriate.

In response to the HSSIB report, the Medical Defence Union says it has been campaigning for the government to provide staff catering and rest facilities to all NHS employees, and the continuation of funding for programmes such as NHS Practitioner Health to support medical professionals who experience burnout.

Professor Peter Brennan, a consultant oral and maxillofacial surgeon at Portsmouth Hospitals University NHS Trust, has spoken extensively about doctor fatigue.

“If you ask residents ‘are you European Working Time compliant?’ most of them would say no,” he says. Professor Brennan says many residents do not want to miss a case – “if they want to come in that is their choice – I am delighted but I am not as well.”

He says that while some resident doctors might be “technically” compliant, many will add on training hours or “not want to upset the boss” and stay back.

Medicine Vs. aviation

In 2021, the RCoS published Hazards of fatigue: learning from aviation [pdf]. The report states that the US National Transportation Safety Board raised the issue of crew fatigue, pointing to tragedies such as the Colgan Air Flight 3407 crash at Buffalo in February 2009.

Although crashes are infrequent, the report says that they gave the aviation industry cause enough “to continue to invest in research to mitigate the risk of crew fatigue”.

Getty/Portra

The college compared the two industries as both represent highly skilled occupations with the requirements for long shifts, often at unnatural times. However, a key difference the report noted is that “even in the simplest aircraft” there are sophisticated computerised support and backup systems in place, as well as there being a degree of standardisation to the equipment.

“Frequently, the same crew will board a flight to limit personnel changes,” it states. “In contrast, medical equipment can be quite different based on manufacturers and there are fewer automated warning systems in place”.

It also suggests that “constantly changing rotas” means that medical staff find themselves in a new environment or situation where their decision making determines whether a patient survives. “It is in these rapidly evolving moments where optimal performance is imperative”.

The RCoS report also states that updated guidelines from the Federal Aviation Administration and European Union Aviation Safety Agency consider commuting, mealtimes, circadian patterns, time zones and time spent on standby in addition to gross duty hours.

“The majority of medical rotas concentrate largely on gross hours,” the report states.

“It is hard to believe that the factors that have been proved to significantly impact human performance in the aviation environment would not have similar consequences in the medical milieu,” it concludes.

Doctors 'more likely' to think about work during time off

Professor Brennan is cautious about comparing the two industries. He says the aviation industry does not face the same workforce pressures as the NHS. “They are limited on their hours,” he says, “they are private companies – in the NHS they haven’t got the manpower to do that by virtue of the numbers involved”.

He also says that while an air crew can park their plane and not think about flying for the time they have off, doctors are more likely to continue thinking about their caseload when they are home.

Nonetheless, he has worked extensively with “high reliability organisations” – a term defined by the US government as industries that achieve safety, quality and efficiency goals through sensitivity to operations, reluctance to simplify (accepting that work is complex and can fail in unexpected ways), preoccupation with failure (viewing near misses as opportunities to improve), deference to expertise and practicing resilience.

He says that the issues with fatigue have been known for “many, many years”.

“I would never compare aviation to healthcare [but] the common denominator is the human element,” he says.

A Department of Health and Social Care spokesperson said the government inherited an NHS with “an overworked, demoralised workforce” and the HSSIB report “highlights the profound consequences” for patients and staff.

Along with an "above-inflation pay rise", the DHSC has recently announced a support package to improve their working lives, including making it easier to take up flexible working and developing new guidance on working patterns, the spokesperson added.

“Through our Plan for Change, we will turn around our health service to cut hospital waiting lists and improve conditions for staff across the country.”

Current workforce pressures will likely make it difficult for the government and the NHS to reduce the factors that lead to fatigue.

Other high reliability organisations are also aware of the issue, and have taken steps to address fatigue – providing more frameworks for comparison for clinical teams, academics and the government to refer to.

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