New standards for living and working conditions for hospital doctors in training
This revised guidance takes forward the provisions for accommodation and catering set out in Living and working conditions for hospital doctors in training.
This is a new agreement reached following discussions between interested parties including junior doctors' representatives, regional New Deal task forces officers and NHS managers.
The agreed standards apply UK-wide.
Introduction
This revised guidance takes forward the provisions for accommodation and catering set out in the new living and working conditions for hospital doctors in training agreement in HSC 2000/036. This agreement is the result of discussions between junior doctors’ representatives, regional new deal task force officers, representatives from postgraduate deaneries, NHS managers, NHS estates staff and other interested parties.
The agreed standards apply UK-wide.
One of the key features of this agreement is the tough penalties on hospital trusts who continue to offer sub-standard accommodation. Trusts can be penalised in three main ways:
1. Accommodation that fails minimum safety standards must be closed immediately and alternative arrangements made. No training posts can be advertised until minimum safety standards are met.
2. Accomodation must be free if accommodation falls below the minimum standard until improvements are completed.
3. Withdrawal of approval for posts by postgraduate deans for sub standard accommodation.
Monitoring of trusts
Hospital trust facilities will be monitored regularly to ensure that standards are maintained and/or improved. The initial phase of monitoring will commence in the first year after the guidance is issued and will follow the process here:
1. Contact by the independent facilities inspection officer with junior doctors and other involved parties
2. Visit to the trust by the facilities inspection officer
3. A maximum of one month later, a report by the facilities inspection officer on each trust is to be submitted
4. To junior doctor representatives, deans and improving junior doctors’ working lives action teams.
5. Trust action plan within 6 weeks with a 6 month limit for actual improvements
6. Subsequent visits to the trust every 6-18months depending on standards achieved
Failure to reach agreed standards or failure to improve within specified time scales will be brought to the attention of regional office performance management function, the improving junior doctors’ working lives action teams, the relevant postgraduate dean, and the royal colleges.
What junior doctors need to do
Junior doctors have an important role to play from the conception to the sustenance/maintenance of hospital accommodation and catering.
• get involved in the planning by contacting your local BMA office, they can put you in touch with your Local Negotiating Committee (LNC).
• satisfy your end of the deal ‘take care of hospital accommodation’.
• ensure that if there are problems that they are dealt with in the agreed way ie reported to the designated trust contact point.
• inform your regional BMA office if you see posts advertised that continue to fail to meet the minimum standards.
The minimum standards
The following lists are not exhaustive, for a more comprehensive list refer to annex a and b in the appendix or the Department of Health circular, HSC 2000/036.
Of general note is that at a minimum, all hospital trusts need to have sufficient numbers of rooms for all on call or partial shift junior doctors. Whether this be during all or part of any particular night on duty.
In addition to this all on call rooms should be of the same standard as residential accommodation, and all married accommodation should be of the same standard as single accommodation.
Bedroom
Adequate light and sound proofing, ventilation, temperature adjustment, and security
• desk, chair, wardrobe, drawers, bookcase, easy chair, reading light
• lined curtains
• wash basin with hot and cold taps
• telephone for external phone calls charged at no more than bt rates
• a safe 5-10 minute walk to relevant wards and departments
Living room and dining area kitchen
• no more than four people sharing
• table with at least one chair per occupant
• cooker (4 rings and an oven)
• tv aerial connection
• microwave
• telephone connection
• fridge-freezer
• kettle, toaster, steam iron, ironing board
• cooking and eating utensils
Bathroom and lavatory
• at most 3 people to a toilet, bath and shower
• at most 2 people to a toilet, bath and shower by August 2003
Other facilities
• on-site parking space if available or a secure alternative for resident or on-call junior doctors
• lounge
• study/reading room
• office area (with facility for it/internet access)
• laundry with adequate number of washing machine and dryers at a reasonable price
• changing facilities and showers
• recreational areas on site or arranged with local sports centres etc. catering for the preferences of a wide range of staff
• secure communal cycle store
Doctors mess
• accessible from wards and departments
• size of facility proportional to number of junior doctors
• one kitchen and dining area
• adequate numbers of toilets and wash basins, not shared with patients or public
Catering in general canteen (if in existence)
• good quality hot and cold at any time • open 365 days a year
• bread, cereals and drinks available at all times
• wherever possible minimum late opening until 11:00pm and a further two hour period after 11:00pm and 7am
• situated away from patients and public areas
• provide a wide range of cultural and dietary options
As before there is a star rating system should the hospital trust choose to provide accommodation above the minimum standard. For further details see the appendix or HSC 2000/036, annex a 7.1-7.4.
Appendix.
The following Department of Health agreement HSC 2000/036 should be viewed in conjunction with relevant housing legislation and NHS Estates guidance
Annex a
Standards for living and working conditions for hospital doctors in training
General
• doctors in training have a responsibility to ensure that they keep hospital accommodation clean and do not cause damage to facilities (fabric, furnishings or equipment).
• where current or future legislation for houses of multiple occupancy cover hospital accommodation, all regulations and powers of enforcement by local authorities will apply. All hospital accommodation must meet relevant legal requirements and NHS Estates guidelines.
The following minimum agreed standards will apply to all hospital accommodation.
A. Minimum housing in multiple occupancy (HIMOR) standard: see annex D
A dwelling is unfit if it fails to meet one of the requirements set out below and, by reason of that failure, is not suitable for occupation. The requirements constitute the minimum deemed necessary for any dwelling to be fit for human habitation. All hospital accommodation must:
• be free from serious disrepair
• be structurally stable
• be free from dampness prejudicial to the health of the occupants
• have adequate provision for lighting, heating and ventilation
• have an adequate piped supply of wholesome water
• have an effective system for the drainage of foul, waste and surface water
• have a suitably located wc for exclusive use of the occupants
• have a bath or shower and wash-hand basin, with hot and cold water
• have satisfactory facilities for the preparation and cooking of food including a sink with hot and cold water.
B. Minimum building requirements
Residential accommodation
B.1. The configuration of accommodation is at the discretion of the employing authority subject to proper consultation with the end-users or their representatives as stipulated in the NHS Estates’ capital investment manual.
However, the following minimum ratios must apply:
• each bedroom should be for one occupant (except in married accommodation);
• each wc, bath and shower should be for no more than three, and by August 2003 no more than two, occupants;
• each kitchen, dining area and living room should be for no more than four occupants, taking into account the
Size of the room.
B.2. Each bedroom should have proper light and sound proofing to ensure the occupant is not disturbed, night or daytime, and should be lockable. In addition, there should be a minimum of two power points; a telephone connected using a standard British Telecom (BT) or cable socket to the internal hospital telephone system; access to the facility for making external calls at no higher than relevant BT rates; and a wash basin with hot and cold running water.
B.3. The temperature in each room should be able to be individually adjusted by the occupant.
B.4. Each kitchen should contain at least four power points.
B.5. Each living room should contain at least four power points, telephone connection and tv aerial connection.
B.6. The washing and sanitary facilities should be arranged to ensure adequate privacy for the user.
B.7. Water closets should be connected to a suitable drainage system, and be provided with an effective means for flushing with water.
B.8. Any room containing a sanitary convenience should be sufficiently ventilated, so that offensive odours do not linger. Measures should also be taken to prevent odours entering other rooms.
B.9. The rooms containing sanitary conveniences should be adequately lit.
B.10. Toilet paper in a holder or dispenser and a coat hook should be provided in each room containing a sanitary convenience. Suitable means should be provided for the disposal of sanitary dressings.
B.11. Showers which are fed by both hot and cold water should be fitted with a device such as a thermostatic mixer valve to prevent users being scalded.
B.12. All appropriate fire and smoke precautions should be installed, according to fire regulations.
On call rooms
B.13. The new deal states that on call rooms should be of the same standard as residential accommodation. The above standards must therefore apply to on call accommodation.
B.14. Hospitals must provide a sufficient number of on call rooms for their junior doctors, including all juniors who are compulsorily or voluntary resident, as demand prescribes. This should be agreed by local consultation with junior doctors and their representatives. Nevertheless, at a minimum there should be a sufficient number of on call rooms provided for all junior doctors who are on call or working a partial shift during all or part of any one particular night on duty (defined in hsc 1998/240 as 10pm to 8am).
B.15. The on call rooms should be a separate unit away from clinical areas, though at a maximum of between 5 and 10 minutes walking distance from the relevant wards. The rooms must not be built next to power plants or goods delivery areas, or other areas that could disturb occupants’ rest.
Doctors’ mess and other common areas
B.16. There should be a doctors’ mess easily accessible from wards and departments. In large hospitals this may require more than one mess. In small trusts a joint mess for all clinical staff may be acceptable.
B.17. All standards stipulated in this document for residential accommodation and on call rooms, including standards for sanitary, washing and kitchen facilities, apply equally to the doctors’ mess, except that:
• there should be access to an adequate number of water closets and wash basins, not shared with patients or the public.
• there need be only one kitchen and dining area.
B.18. The following areas should also be provided for staff on site, wherever is most appropriate, and not necessarily exclusively for junior doctors:
(i) lounge (with power points, telephone connection and tv aerial);
(ii) study/reading room (with power points);
(iii) office area (with power points, telephone connection and the facility for it/internet access);
(iv) laundry with an adequate number of washing machines and dryers (reasonably priced and wellmaintained).
(v) changing facilities and showers;
(vi) bar/games room/fitness room or alternative recreational arrangements, catering for the preferences of a wide range of staff.
Miscellaneous
B.19. Access to and from the on call rooms, doctors’ mess and clinical areas should be safe and without risk to health or welfare, for example, well lit.
B.20. On-site security and safety policies and procedures must be agreed with staff, including junior doctors, and implemented.
B.21. Secure, communal cycle store.
B.22. Resident or on-call junior doctors should have access to a parking space near their accommodation where onsite car parking is available. Where this is not available, employers should attempt to ensure that alternative secure parking arrangements are in place.
C. Minimum living and working conditions
The standards below assume the following minimum conditions:
• all decoration should be free from damp/leaks and clean
• all furniture must be in working order and fire retardant.
Accommodation
C.1 separate standards do not exist for married accommodation as the standard must be the same as for single
Accommodation with changes to be made only as appropriate for married accommodation.
C.2 bedroom (NB – one per occupant)
C.3 bathroom (NB –one between three, working towards one between two occupants)
Shower; bath; toilet – all must be provided
C.4 kitchen (NB – one between four occupants)
C.5 dining area (NB –one between four occupants)
Table;
At least one chair per occupant.
C.6 living room (NB – one between four occupants)
C.7 miscellaneous:
Exercise/sporting facilities for all staff – where this is not possible, employers should make arrangements with
Local sports centres and swimming pools and should inform juniors of these facilities.
Catering
C.8 junior doctors on duty must be able to get good quality hot and cold food at any time. If the canteen is closed, this should be through a supply of microwave meals, cold cabinet or a similar arrangement.
Supplies should be sufficient for all staff on duty, and readily accessible to doctors in training. Supplies should be regularly restocked, with swipe cards or change machines provided where necessary.
The inability to obtain hot food for any reason will result in failure to meet these minimum standards.
C.9 where the canteen is shut or there is no canteen, alternative facilities must be available – for example microwave meals (where possible, in the doctors’ mess); local agreements with delivery fast food retail outlets.
For takeaway food; and/or a trolley service. Bread, cereals and drinks should be available at all times.
C.10 in small trusts (where there are less than 10 junior doctors on-call at any one time) canteen opening hours can be reduced from the minimum standard set out below. However, the minimum standard (availability of good quality hot and cold food round the clock) must be observed.
C.11 canteen
Where catering facilities exist, they must be open 365 days a year.
Meals provided must be adequate, varied, attractively and efficiently served and freshly prepared.
Canteen must be open and serving hot food for extended meal times for breakfast, lunch and dinner, wherever possible with a minimum late opening until 11.00pm and a further two hour period after 11.00pm and before 7 am.
Canteen must always provide healthy eating options and a vegetarian option, and should provide for a range of cultural and dietary requirements.
Serving and dining area must be situated away from facilities provided for patients, relatives and other nonemployees.
D. Star rating system
Once all the above minimum living and working conditions have been achieved, employing authorities may improve
The facilities offered to junior doctors by including the following details:
Incorporating five of the following items = one star
Incorporating ten of the following items = two star
Incorporating fifteen of the following items = three star
This will encourage trusts, for just a small extra investment, to attract junior doctors to their hospital by providing accommodation and other facilities of a high standard.
D.1 bedroom
D.2 kitchen
D.3 living room
D.4 miscellaneous
Annex B
Inspection, monitoring and enforcement of standards
1. Trust facilities must be monitored regularly to ensure that standards are maintained and/or improved. This guidance aims to ensure consistency across regions and deaneries in interpreting standards and taking enforcement action.
There is scope for eliminating duplication in inspecting accommodation and catering facilities, whilst recognising the need for deaneries and royal college training advisors to visit to address education and training issues.
Facilities monitoring
Function
2. Regional offices are required to designate the duties of facilities monitoring to cover each trust within their Region. The facilities monitoring function will be to provide an independent third party inspection of trust facilities, visiting sites on a regular basis and working consistently with trusts to draw up plans for any necessary improvements.
This system is already being used successfully in at least one English region.
This function fits well alongside the key role of regions in providing trusts with independent advice and managing their performance on wider juniors’ issues, eg improving hours, monitoring and tackling problem posts – which will, of course, assume much greater importance as we step up the impetus to secure 100% hours compliance with current targets and to start to implement the working time directive for doctors in training.
3. Regions may wish to take a multiprofessional approach and make arrangements which cover inspection of living and working conditions for non-medical as well as medical staff , especially in view of the trend towards 24-hour services which implies an increase in on-call, weekend and/or night work for staff groups who may not traditionally have adopted such working patterns.
This will be consistent with the approach of improving working lives and the HR performance framework, which set targets to improve and accredit the living and working conditions of all staff including doctors.
Remit
4. The officers performing the facilities inspection function will be responsible for inspecting the living and working conditions of junior doctors and recommending enforcement action to ensure that the standards specified in annex A are met.
This includes accommodation, catering arrangements, doctors’ mess and rest areas , and safety and security issues, but not educational facilities, which are the remit of the postgraduate Deans and royal colleges.
Accommodation includes both on-call and compulsory residential accommodation, and voluntary residential accommodation which may be used for on-call purposes. The standards against which facilities will be assessed are set out in annex A.
5. Facilities inspection officers will be responsible for ensuring that breaches of standards or failure to improve within the specified timescales are brought to the attention of the regional office performance management function, the regional taskforce or equivalent, the relevant postgraduate dean, and the royal colleges.
Responsibility for applying sanctions where minimum standards are not met rests with the appropriate body as set out in the guidance on enforcement below.
Frequency and mechanism of visits
6. Initially each trust should be visited in the first year after this guidance is issued. Before each visit, the officer performing the facilities inspection function should make contact with the trust facilities officer, Medical Director, postgraduate tutor and, most importantly, with junior doctors themselves both through their representatives and through organised mess meetings and/or informal meetings.
Standard questionnaires are a useful way of obtaining input in advance of the visit.
7. Within one month after the initial visit, the officer will produce a report on each trust and submit it to the regional office performance manager, regional taskforce or its equivalent at Regional Office, the dean, the Royal Colleges, the junior doctor representative and the trust itself.
The regional office will ensure the trust submits an action plan within 6 weeks of the report for improvements where these are required, and will inform the trust of the consequences of failing to meet these targets.
8. Subsequent visits will take place at intervals of between 6 months and 18 months thereafter depending upon the standards achieved and action plan or other enforcement action still to be carried out.
Trusts will be required by regional office to demonstrate progress six-monthly until they can be accredited as meeting the minimum standards in annex a; trusts meeting these standards can be visited less frequently.
All visits will result in a progress report to the regional office copied to interested parties. Where minimum standards have been achieved, the trust lnc can alert the facilities inspection officer at any time and request a visit if ad hoc problems have not been resolved locally.
Enforcement
9. The accommodation and catering standards outlined in annex a must be implemented, adhered to and enforced, and will contribute to accreditation for the improving working lives (iwl)standard. It is the responsibility of trusts to take action to improve standards, and of regional offices to performance manage them and to help them work towards accreditation at IWL pledge, practice and practice plus levels.
10. It is the responsibility of regions, where appropriate through postgraduate deans, to take action to enforce compliance with the agreed minimum standards.
11. A staged approach should be taken to the enforcement of minimum standards and the encouragement of “best practice” improved standards. Enforcement will require the following action when minimum accommodation and catering standards [annex a] are not met.
12. For failure to meet the standards set out in annex a – where the work is relatively minor and achievable without major outlay:
An action plan should be drawn up within six weeks of the inspection report to specify the remedial work or organisational change which needs to be done to meet the accommodation or catering
Standards. The improvements should be completed within 6 months or less. The trust will be visited at the end of this time to check on progress.
13. For failure to meet the standards set out in annex a – where remedial work would require major investment:
Trusts will be required by the regional performance manager to draw up an action plan within six weeks of the visit showing how they intend to address these problems and within what timescale.
Realistically this will need to take into account factors such as the trust’s financial position, structural/organisational changes (eg impending merger), future medical staffing levels, split site
working, Private Finance Initiaitve (PFI) arrangements etc.
The expertise of regional estates officers will be invaluable in this context. Action plans with a realistic timescale to resolve the problem will need to be agreed with all interested parties (ie the trust, the dean, the taskforce or equivalent, regional performance management and the local negotiating committee).
14. Where minimum standards are not met for accommodation, the provisions of revised paragraph 175a of the hospital medical terms and conditions of service will apply (see annex e). This will oblige employers to provide accommodation free of charge until such time as improvements have been completed. This change to terms and conditions of service will be promulgated in a separate advance letter.
15. Where the minimum agreed standards are not met, training posts should be advertised accordingly.
16. Where, despite an action plan agreed by all parties, improvements have not been completed within the agreed timescale, no training posts can be advertised until the trust has reached minimum standards.
Trusts would also be required to find alternative accommodation for any trainees in post, and to provide transport to and from hospital if necessary.
17. In accordance with standard performance management approaches, regional offices (through the Regional Task Force (RTF) or equivalent) will expect postgraduate deans to apply their powers under HSC 1998/229 to withdraw approval for posts. Incumbents would still have approval until they completed their contract.
18. Where living and working conditions fail annex a minimum standards, new deal accreditation, if previously awarded to the trust, must be withdrawn.
HIMOR failure- steps to take
19. Where inspection suggests that junior doctors’ living and working conditions are so poor that they may not meet minimum legal requirements, the inspection officer should inform the local authority environmental health department.
Local authorities are responsible for inspecting accommodation for fitness for human habitation, and taking appropriate action (eg improvement notices or closure) where legal minima are not met.
Annex d sets out the provisions of the relevant legislation (houses in multiple occupation regulations – HIMOR).
20. Where the local authority confirms that accommodation has failed HIMOR standards and has issued a closure notice, all on-call and compulsory accommodation and voluntary accommodation used for on-call purposes must be withdrawn from service until the himor notice has been lifted.
The trust must provide alternative accommodation, with transport to and from the hospital if necessary. Trusts must take steps as a matter of urgency to provide accommodation which meets local authority requirements and minimum annex A standards within twelve months from the date of the HIMOR notice.
21. During this 12 month period, or until the annex a minimum standards are met, if sooner, the trust would be unable to advertise training posts as having postgraduate dean approval. Incumbents would still have approval until they completed their contract if this had less than 12 months to run.
Should the trust fail to provide accommodation which meets these standards by 12 months after the date of the notice, postgraduate Deans should withdraw deanery funding and approval for posts in accordance with the provisions of HSC/1998/229 and would be required to find alternative posts for any trainees in post when approval is withdrawn.
22. Where voluntary accommodation fails himor standards and has been issued with a closure notice, it must be withdrawn from service until the himor notice has been lifted. The trust must provide alternative accommodation until the HIMOR notice has been lifted or until the junior’s contract comes to an end.
The Trust will meet the cost difference on juniors’ behalf if the new accommodation is more expensive. The trust, as a result, when advertising the new post will have to make it clear to applicants (both UK and overseas) that they will have to find their own accommodation.
23. Where accommodation (on-call, compulsory residential or voluntary) fails HIMOR standards and is issued with an improvement notice, a trust must offer alternative accommodation to those in post and take steps to meet standards as outlined in the two preceding paragraphs.
Residents may choose to remain in the premises whilst improvements are carried out if this is feasible, in which case the abatement provisions of paragraph 175a of the hospital medical terms and conditions of service will apply. This will oblige employers to provide accommodation free of charge until such time as improvements have been completed.
24. Where accommodation (on-call, compulsory residential or voluntary) fails himor standards, new deal accreditation, if previously awarded to the trust, must be withdrawn.
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