The trainee crunch

Authors: Karen Low 

Publication date:  04 Nov 2009

Ingrid Torjesen’s article for BMJ Careers looked at the serious shortage of doctors nationwide at the start of 2009 and particularly the impact of abolishing permit-free training.[1] Here we look at the effect of the August changeover and the European Working Time Directive (EWTD) on the situation.

Hywel Dda NHS Trust is one of the many trusts that are affected. A spokesman said, “Despite sustained efforts to recruit, there are just not enough available doctors. On 27 July 2009, the projected number of total vacancies across the trust was 62.”

Dr Mary McGraw, vice president for training and assessment at the Royal College of Paediatrics and Child Health, said, “There is a continuing problem with vacancies in training programmes; 75% of vacancies are in middle grade rotas and 25% in junior rotas. A recent survey of clinical directors suggested that at the time of reporting there may be an average of three vacancies per service.”

Barry Pactor, marketing and international director of recruitment firm HCL plc, has seen a considerable increase in the number of vacancies for junior doctors within the NHS in the past year. “We found the two main reasons for this increase were not enough graduates entering the workforce and the European Working Time Directive reducing the number of hours to 48 a week.”

48 hours and no more

Since 1 August 2009 the EWTD has applied to all trainee doctors. On average, over a 26 week period, a doctor must not work for more than 48 hours in a week.

Remedy UK surveyed doctors the first month after implementation of the EWTD (www.remedy.uk.org). Responses indicate 47% of doctors’ rotas fail to comply with EWTD regulations. The apparent reason for the discrepancy is that a large number of rotas meet the target on paper, but fail to do so in practice.

The 48 hour week has had two effects according to Dr McGraw. “More service posts have had to be created to make the rota compliant. These posts are difficult to fill. Secondly, there is no flexibility for doctors within rotas to cover any gaps that occur as they are already working 48 hours, and to exceed this would mean they would break the directive. Therefore, the introduction of the directive has increased the vacancy rate. Paediatrics has the highest number of trusts that have applied for derogation because they are unable to meet the directive and we are expecting that more may need to apply. Our survey suggests that of the rest, although their rotas would be compliant if all the posts were filled, a high proportion do not meet the directive because of the vacancy rates.”

The opt out option

Many trusts are asking doctors to opt out of the directive to cover gaps as internal locums.

Shreelatta Datta, chairman of the BMA Junior Doctors Committee, says, “Solutions will not be found until we have honesty. We cannot continue to rely on junior doctors working extra unpaid hours to prop up our healthcare system. Doctors working on understaffed rotas have serious concerns about standards of patient care. For too long the NHS has relied on junior doctors working beyond their contracted hours; the time has come to stop papering over the cracks and deal with the issue.”

Dr McGraw asserts that paediatricians are working hard to ensure patient care is not compromised. However, “The majority of units surveyed reported that consultants are undertaking additional work and trainees are working additional shifts, and so both are working over the directive limitations.”

Article 5 states that a worker can agree with their employer not to apply the limit of 48 hours a week to that worker. Employers must keep a list of which workers have opted out, how long they have opted out for, and how many hours they are working. This does not exempt the worker from the rest requirements in the legislation or in their contract, nor does it exempt them from the hours’ limit in their contract.[2] New Deal limits of 56 hours a week still apply.

The BMA guidance is clear. “The individual opt out is not an appropriate mechanism to solve problems with Working Time Regulations/EWTD implementation, especially those to do with training. We have a variety of concerns, including juniors not being appropriately remunerated for additional work; a differential training system developing for those who have opted out and those who haven’t; and decreasing the incentives on employers to solve problems with training and staffing issues.”

Remedy UK’s view is not entirely in agreement. Richard Marks, head of policy and legal for Remedy UK says, “Remedy believes that the individual opt out should allow doctors to get better experience, and therefore should be supported. But we do not approve of circumstances where doctors are arm twisted or coerced into it.”

Training and morale

Clare Marx, past president of the British Orthopaedic Association, says that surgical training has been suffering. “The individual opt out is a matter for each doctor. However we do not support a formal move to extend the working hours beyond the 56 hours of the individual opt out. The problems of delivering service have impacted on the training opportunities, particularly for the most junior trainees. Service redesign is essential to ensure safety for patients, and training for surgeons and extended hours will not be the overall solution to this.”

Dr McGraw has concerns about the impact on training. “Trainees are spending all their time in acute care and not having the opportunity to gain experience in the other aspects of the curriculum, in particular long term condition care.”

Tom Dolphin, vice chairman of the BMA’s Junior Doctors Committee, writes in The State of Postgraduate Medical Education and Training 2009 about the challenges being faced. [3] “One of the challenges for employers will be that they have to prioritise training in its own right, not as a mere fortuitous by-product of the service. Training will no longer just happen by accident while the trainees are at work.

“Employers have often not prioritised training for the future, instead focusing on service provision now. The amount of service work that needs to be done has not decreased with trainees’ hours. Patients need to be seen now, yes, but they will also need properly trained consultants and GP principals in the future. It may work now to have the rotas heavily weighted towards service, but the potential consequences for training are obvious to anyone, especially in the craft specialties.”

Remedy UK says the survey “paints a picture of disillusion and demoralisation among doctors, and bullying and manipulation from management.” Richard Marks says, “The 48 hour week makes it much harder to organise training within a department, because the opportunities for consultant trainee interaction are reduced. It also makes the lives of trainees worse, since they are working in isolation and there is much less of a team spirit. A big complaint that many trainees have is that of “split weekends,” which means that more weekends are hit by work.

“Many hospitals have gone over to mandatory annual leave as a way of coping with the EWTD requirements; this is very unpopular.”

Dr Dolphin confirms, “The reported bullying of trainees to under-report their hours or opt out is unacceptable.”

Where to from here?

Dr Datta wants change. “In the current economic climate it is paramount that the NHS is run efficiently. For years the BMA has been calling for the problem of understaffed rotas to be addressed. It is high time the government started to work with the profession to solve the understaffing problems so that junior doctors can deliver high quality care to their patients and receive the training they need to be the consultants of tomorrow.”

Ramesh Mehta, president of the British Association of Physicians of Indian Origin (BAPIO), warns that the medical training initiative is not an easy answer. “Lots of the international doctors are concerned that the jobs are advertised as training but are only service. In addition BAPIO have strongly recommended that the length of the medical training initiative be extended by six months to ensure these doctors are allowed time for a proper induction into the British healthcare system.”

Dr McGraw discusses possible options. “There are few solutions that can solve the problem in the next few months. We have recommended increasing the number of consultants so that the service is less reliant on trainees to provide the service—a much more sustainable trained doctor solution. Additionally, the numbers of doctors entering training should be increased so that there is an excess of doctors relative to posts at the level of the predicted vacancy rate. Deaneries have been doing this but it will take three to four years to solve the problem because trainees will be entering at a junior level and the vacancies are at the more senior level.”

Although doctors are working hard to ensure patient safety it is clear that the current situation cannot continue. Dr McGraw warns, “Ultimately it is not sustainable to run the number of acute rotas with the number of doctors available, and service reconfiguration needs to be considered.”

Competing interests: Karen Low is the specialty trainee 1-3 paediatric trainee representative for Severn Deanery.

Karen Low freelance medical journalist; specialty trainee 2 paediatric trainee

 karenjhebert@googlemail.com