Is the European Working Time Directive going to work?
Authors: Lynn Eaton
Publication date: 21 May 2008
Ironically the BMA, one of the fiercest campaigners for doctors’ shorter working hours, is now among those sounding warnings of the impact it will have on members’ careers. Shorter hours may improve junior doctors’ home lives, and it may mean a better service for patients as the doctors should be less tired, but the BMA argues it’s also going to make it difficult to fit in all the training needed to gain the certificate of completion of training that will enable doctors to rise to the rank of consultant.
There was some concern about the impact on training when the current 56 hour limit was introduced in 2004, but according to Roy Pounder, who has been leading the work on the directive for the Royal College of Physicians, many feel its effect on training has so far been minimal.
All that is set to change, however, when the 48 hour limit begins. The fear is that as trusts struggle to devise rotas to cover patient need, training needs may be given even lower priority than they are now.
Trusts have no choice about complying—chief executives will face a fine if they don’t. A hard pressed manager will see patient need as a more immediately important demand than doctors’ training.
Hassan El Hassan, a member of the BMA Junior Doctors Committee and a year 1 specialist trainee working in ear, nose, and throat surgery, has direct experience of this. He was working in a pilot 48 hour compliant rota system where he had to take the next day off after working an on-call shift overnight.
“In terms of training, that’s catastrophic,” he said. “You admit all these patients the night before and you want to know what’s wrong with them. How do you know whether you did right or wrong if you can’t go on the post-take ward round?” He raised his concerns with the trust, “but nobody knew the answer, or they would have changed it.”
Many trusts are piloting rotas that aim to tackle the problem of providing enough doctor hours to meet patient demand (see Pilot projects box).
Professor Pounder, who has become an expert on the pros and cons of the various rotas, is clear of one thing: “Where [the trial of the 48 hour week] has worked,” he says, “it is because a charismatic leader has driven it through. But all we tend to hear about is how exceptionally difficult it has been.” Whatever way you look at it, there are going to be fewer doctor hours available, he says. You are taking away 8 hours a week from every doctor. That’s going to be one less day a week.”
Everyone acknowledges that the impact of the directive differs from one specialty to another. And because there is no easy measure of how many hours’ training is required, managers are no doubt struggling with the “how long is a piece of string” approach that is characteristic of medical training in the NHS—and which is fiendishly difficult for trusts to plan for.
In surgery, for instance, trainees need to spend time practising certain techniques. Familiarity with a procedure is important, as is manual dexterity. Merely clocking up the hours is not enough; trainees will need to demonstrate their skills through an annual clinical appraisal, and some will acquire the skills faster than others.
While a shorter week will almost inevitably reduce exposure to surgical operations, it may not matter so much in other specialties. “In cardiology, SpRs [specialist registrars] will need to be able to get stents in,” says Dr El Hassan. “But in A&E [accident and emergency] it won’t matter at all [if you only work 48 hours]. In fact bring on the 40 hour week in A&E!”
Continuity of care is an issue in general medicine, says Professor Pounder, where a patient is in hospital for an average of 7.2 days. Doctors will be able to monitor patients’ progress far better if they see them more regularly than by merely picking up handover notes, he argues.
Consultant general physicians will need to be there 24 hours a day. In theory at least, a junior doctor could receive training in general medicine at any time, day or night.
Anaesthetist Peter Maguire, a member of the BMA council and chair of its working time directive group, says the number of procedures a trainee needs to perform in his or her specialty has already been reduced.
“In 1996 when I was working as an SHO [senior house officer] I had to do 1300 procedures in a year. Now these things are much lower. Whether 1300 cases was necessary could be debated, but I had a very sound apprenticeship.”
There may be more junior doctors coming through, but without adequate training their prospects of reaching consultant level look increasingly slim.
And Dr Maguire points to one final sting in the tail: “Many doctors haven’t even thought about the impact on pay. The vast majority of doctors are paid on band 2, which is a 48-56 hour week. But all working time directive jobs will be band 1 because they are below 48 hours.”
Timeline
1993—European Union states agreed to the European Working Time Directive, a piece of health and safety legislation designed to protect workers from the dangers of overwork. The United Kingdom won an opt-out, allowing some employees (including consultants) to be excluded. Doctors in training were also excluded initially, but it was later agreed the directive should gradually be phased in for them. Consultants remain outside the directive.
2000—Following a case brought by Spanish doctors against their employer, SiMAP, the European Court of Justice ruled that all hours spent compulsorily resident at the place of work should count as work, meaning on-call rotas with assumed rest periods counted as work.
2003—A second European Court of Justice case, the Jaegar judgment, reinforced the earlier ruling about hospital based on-call rotas.
2004—The 58 hour limit began, as the first stage towards full implementation, phased over five years.
August 2007—The 56 hour limit began.
1 August 2009—The 48 hour limit begins.
Pilot projects
A number of pilot projects are testing new rotas and approaches to service configuration that will meet the new working time limits.
Homerton Hospital in east London has adopted a “hot and cold” approach, with different staff rotas for emergency (hot) and elective (cold) care. “Because we are on one site, it is relatively straightforward,” says John Coakley, medical director.
The emergency team is headed by a consultant physician, with support from eight doctors in training, from foundation year 2 to specialty trainee year 2 level, drawn from the elective specialties. The emphasis is on general medicine and surgery, with a smaller input from neurology and orthopaedics. The team works 12 hour shifts, for 12 weeks a year (in two six week stints). The night shift in A&E runs from 9 pm to 10 am, but a consultant physician is in at 8 am to do the post-take ward round, so junior doctors will be around to find out what happens to patients they have admitted.
Meanwhile, elective work is covered by each specialty on a nine to five, Monday to Friday basis. “I’m sure there were other ways of doing it—but I couldn’t think of any,” says Dr Coakley.
In Manchester, the European Working Time Directive has been the catalyst for a reconfiguration of paediatric services, which were provided on 13 different sites. In future, 24 hour cover will be available on only eight sites, while the others will be daytime only.
“It’s not necessarily about increasing the number of doctors,” says Dr Yasmin Ahmed-Little, project director for the working time directive in the north west. She is based in the deanery and says this has made it easier to check what impact a trust’s plans will have on training. Royal colleges have had to be more precise about how many training hours they expect before a doctor can be awarded the certificate of completion of training, she says. And some specialties, such as surgery, have had to consider alternative methods of learning, such as simulation models rather than real patients.
At the Countess of Chester Hospital, for example, where they have changed to a hospital at night model, clinical director David Ewins says they have also introduced more e-learning. At night there is a single team for the entire hospital, with advanced nurse practitioners, rather than junior doctors, triaging emergencies. There is no elective rota. The shift is 13 hours to ensure an hour’s overlap between staff.
They have also arranged training to ensure that the medical registrar leading the night team has the requisite skills. “This is health and safety legislation that won’t go away,” says Dr Ewins. “It has got to be done.”
For more details see www.healthcareworkforce.nhs.uk/working_time_directive/rotas%2c_handover_and_escalation_tools/wtd_compliant_rotas.html.
Lynn Eaton freelance journalist
London
Related adverts
- SPR in Anaesthesia required in the West Midlands in the ITU, Obstetrics and general departments. Commencing ASAP for at least 3 months.
- Locum SpR Anaesthetist required for an immediate start in London until April, covering all areas including ITU. On calls may be available.
- Locum SpR/SG Anaesthetist required overseas a.s.a.p then continuing on a month by month basis.
- Locum SpR/SG Anaesthetist required overseas from 1st February until the end of July. Hours will be as per rota with 1:5 on calls rota.
- SpR Anaesthetist required for an immediate start in the North East for 1 month with accommodation available.
