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Dr. Murrison: Is the Secretary of State aware of the report published recently by the Royal College of Physicians? It suggests that the move towards compliance with the new working week has resulted in a reduction of quality not only in clinical care but in the training of junior doctors. Does he agree? If he does, what is he going to do about it?
Alan Johnson: I reject it completely, for reasons that I shall come to in a second.
The Government supported the amendment to the directive and its gradual implementation, not least because there is irrefutable evidence that tired doctors present a risk to patient safety. The Government never want a return to a situation that many established doctors will remember only too well. It was common for trainees to work through the weekend until Monday evening, with no provision for any breaks—a continuous shift of 90 hours. They would then return to work on Tuesday morning for another shift of at least 36 hours.
Dr. Stoate: I should point out that there is another doctor in the House. On a serious point, I was one of the doctors who had to work many more hours than is currently legal. Is the Secretary of State aware of a report by Warwick and Harvard universities that showed that doctors who worked 56 hours made 30 per cent. more mistakes than those working 48 hours? Even relatively few extra hours significantly increases the risk of making an error.
Alan Johnson: Not only am I aware of that research, but I intend to quote it chapter and verse later.
In acute disciplines, a working week of over 100 hours was the norm, with most of that time spent directly caring for and even operating on patients, with often the most critically ill patients being initially seen by the least trained staff. That is why it is even more important that there are sensible limits to the number of hours staff work to break that culture once and for all and to ensure that no medical professional is required or expected to work dangerously long hours again. For this reason and many others, the British Medical Association is supporting the full implementation of the directive for all junior doctors.
There is no question but that it has been challenging to work towards full compliance. The NHS has over 46,000 doctors in training at any one time. Incidentally, there is no vacancy problem, as the hon. Member for South Cambridgeshire (Mr. Lansley) suggested. On the last set of figures, we had a 95 per cent. fill rate; there is absolutely no vacancy problem anywhere in the country that I know of. This is a service that by its very nature has to operate for 24 hours a day, seven days a week. Trainee doctors need to train and work in as many medical disciplines as possible to become good doctors. Hospitals have had to make dramatic changes to how staff work. So, yes, it has been difficult, but it is simply not true to say that the NHS is ill prepared to achieve full compliance by August this year. We have provided substantial financial support to the NHS to help it to meet the requirements of the directive—£110 million in the current financial year, rising to £310 million for the year to come.
We are working closely with the royal colleges, including the Royal College of Surgeons, and with the BMA and all strategic health authorities, to ensure that we have as
accurate a picture as possible of how well prepared trusts are for full implementation. At present, two thirds of junior doctors are working no more than 48 hours per week, and many trusts, including almost all those in the north-west, are already fully compliant with the directive. In December, we agreed a quality assurance process with the SHAs and the royal colleges to examine potential difficulties and ensure that there are action plans to secure full compliance. The first quality assurance return was received at the end of January, the next is due towards the end of this month, and they will then be received monthly until August. The content is routinely shared with the Academy of Medical Royal Colleges and the National Reference Group, on which the Royal College of Surgeons, the Royal College of Anaesthetists, the Royal College of Paediatrics and Child Health, the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians, the BMA and the SHAs are all represented. There is a rigorous process to ensure that this is being implemented successfully.
There are, of course, still some areas that are struggling: in specialisms such as surgery and 24-hour immediate patient care; or in more isolated, rural parts of the country where there is a shortage of trainee doctors. We have therefore notified the European Commission of our intention to derogate for these areas. It needs to be made clear that the derogation does not mean opting out of the directive: it will mean a maximum working week, for certain disciplines, of 52 hours; and within three years, full compliance with the directive must be achieved.
Norman Lamb: The Secretary of State said that the individual opt-out could not be used for junior doctors, as has been proposed by RemedyUK. What did he mean by that? It seems to me that as long as the individual opt-out applies, it is as applicable to the health service as it is to anywhere else.
Alan Johnson: Yes, the individual opt-out does apply. The mistake is in thinking that there is an ability to get a sectoral opt-out for a complete sector of the working population. I will come to that in a moment.
The Royal College of Surgeons recently argued that there should be a sector-wide opt out for trainee surgeons, who should be granted the right to work a maximum week of 65 to 70 hours—a position that the hon. Member for South Cambridgeshire has said the Opposition disagree with. I met John Black, the president of the RCS, and his colleagues, a few weeks ago to explain that I could not accept their demands even if I agreed with them, which I do not. My reasons are threefold.
First, even if a sector-wide opt-out from the maximum 48-hour working week were desirable, it is not possible under the terms of the directive. The only opt-out allowed by the directive is not sectoral but individual. Even if a sectoral opt-out were possible, it would not be practical to consider surgical care or any one discipline separate from other specialisms. However, the right to the individual opt-out is not automatic under the directive. The directive does not directly entitle anyone to opt out. It gives EU member states the option to legislate that individuals can opt out—a course that we have followed in the United Kingdom—or to deal with the issue via collective agreements in order to enshrine the same individual rights. In Germany, for instance—this has been cited by the RCS—unions and industry representatives
have collective agreements to use the opt-out in specific professions, including doctors, enabling those covered by the agreement to work 54 to 60 hours a week—but within those agreements staff are still required to make an individual decision to opt out.
The RCS has claimed that there are sectoral exemptions for employees working in the armed forces, the fire service and the police. That is incorrect. The police and the armed forces are exempt only in times of national emergency.
Mr. Lansley: Will the Secretary of State consider the proposal—it came from RemedyUK but moves in the direction that the RCS is looking for—to have, in effect, a collective agreement to allow junior doctors individually to opt for a 56-hour working week?
Alan Johnson: The hon. Gentleman misunderstands. Getting a sectoral agreement that allows individuals to opt out would put us in exactly the same position as we are now. We took the legislation route; the Germans, because of their history—they do not even have a national minimum wage, but use collective agreements—took the collective agreement route. The result is exactly the same. Any individual, including junior doctors, has the right to opt out enshrined in the legislation.
Mr. Lansley: Let us cut to the chase. At the moment, the NHS, under the instructions sent by the NHS chief executive to the trusts, does not offer to retain 56 hours. It goes to 48 hours and that is it—an absolute commitment, in the words of the chief executive, presumably at the Secretary of State’s behest. Will the Secretary of State therefore say that that is no longer the Government’s policy for the NHS, and that the NHS is in fact willing to discuss with the BMA, the royal colleges and the associations the implementation of 56 hours based on individual opt-out?
Alan Johnson: There are three reasons I disagree with the RCS. The first is the fact that this cannot be done under the agreement; I will explain later why it should not be done even if it could be. In any case, in the situation that the hon. Gentleman raises, the individual opt-out will be available, but individual workers cannot be coerced into taking it up. It would be wrong for the chief executive of the NHS, or any other organisation, to write to people saying that the 56-hour week is still available. If an individual wants to opt out, anyone can choose to do so under the directive.
Dr. Stoate: Does my right hon. Friend share the worry that if individuals could opt out, it would be case of saying, “Sign this or whistle for your reference”?
Alan Johnson: My hon. Friend makes a really important point. There were serious allegations that that was happening in the early days of the working time directive, but it has not happened since.
I was talking about the emergency services. Normal emergency service activities that can be planned in advance would not allow for the opt-out; it is only there for emergency services when there is a national emergency.
The second reason I cannot accept the Royal College of Surgeons’ recent demands, or indeed the policy proposed by the hon. Member for South Cambridgeshire, is that I
reject the argument that reducing the hours worked by junior doctors will reduce the quality of their training. There is no evidence that with the gradual reduction in junior doctors’ hours over the past 10 years, training is any less effective. The number of junior doctors who fail their training has remained static. We have gone from 72 hours down to 58 hours and on to 56 hours, with the same Jeremiahs saying that that would prejudice proper training, but there is not a single smidgeon of evidence that that is the case. The number of junior doctors who fail their training has remained static. No junior doctor who fails to demonstrate the competencies required is allowed to progress, and we still have one of the most intensive training regimes for junior doctors in Europe.
Having trainee surgeons working longer hours and spending regular periods as a resident on call at night does not afford more opportunities for training, or necessarily mean better training. Very little training takes place in the dead of night, when only very urgent surgery is carried out. Surgery is a technical skill and the way in which surgeons train is evolving. Developments in new technology such as virtual reality surgical simulators mean that there is increasingly and thankfully less need for inexperienced trainee surgeons to practise their skills directly on patients.
Norman Lamb: Will the hon. Gentleman give way?
Alan Johnson: No, I am not giving way. In some parts of the country where the directive has already been implemented, teams of trainee surgeons work on a shift system with senior trainees on call to deal with surgical emergencies. Others have split elective and surgical work so trainees get to experience both.
My third and final reason for rejecting the call by the Royal College of Surgeons is that I completely reject the claim that a reduction in the working week of trainee surgeons will jeopardise the safety of patients. Those who make this argument—including the Opposition in their motion—claim that to have shorter working hours reduces cover in hospitals. But hospitals are addressing that by organising trainee teams and rotas differently, and it is beyond doubt that doctors who are required to work long hours are more likely to make mistakes that could threaten the lives of patients. As long ago as 1998, my noble Friend the eminent surgeon, Lord Darzi, published a paper in The Lancet on the effect of sleep deprivation on surgical trainees, which showed that being deprived of sleep for 24 hours had the same impact on surgeons’ performance as a blood alcohol level higher than the legal limit for driving.
Most recently, a study by Warwick university medical school—referred to by my hon. Friend the Member for Dartford (Dr. Stoate)—on trainees working in Coventry and Warwickshire university hospitals compared the number of errors made by junior doctors working no more than 48 hours with those working no more than 56 hours, and it showed that those working fewer hours made 30 per cent. fewer clinical errors. In the US, where junior doctors work around 80 hours a week, 50 per cent. admit that they have made errors because of fatigue. That reflects the study published in the British Medical Journal in 2001, which showed that surgical trainees were much more likely to make mistakes during the daytime after being on call at night. To complete the
process, a study by the Harvard work hours, health and safety group published in The Joint Commission Journal on Quality and Patient Safety shows that junior doctors who have worked traditional shifts of more than 24 hours have a greatly increased risk of crashing their car driving home from work, as well as of making a serious, even fatal, medical error.
Over the past 10 years, the NHS has put considerable effort into preparing for full implementation of the European working time directive. It is worth pointing out—this would have been my fourth reason if I had thought of it earlier—that longer hours particularly disadvantage women. Some 60 per cent. of medical students are women. All the professional bodies agreed with the objective when this agreement was signed in 1999-2000. I have no idea why the Conservative party wants to be the champion of long hours and staff exploitation. I hope that the House leaves its arguments where they belong: in the last century. I commend the amendment to the House.
8.14 pm
Norman Lamb (North Norfolk) (LD): I welcome the debate. It comes at a timely point in the build-up to the change in August and it is important because of the massive potential problems that are emerging. I am conscious of an extraordinary gap between what the Secretary of State says about the potential risks involved in the changes and what the professionals working in the service have said, loud and clear. The Secretary of State ought to listen a bit more carefully to the royal colleges, because their analysis of the risks we face as a result of the changes is different to his. He ought to listen to the people working in hospitals, who have experience of the way in which the reduction in hours impacts on patient care.
Mark Hunter (Cheadle) (LD): My hon. Friend rightly draws attention to the comments of the president of the Royal College of Surgeons, John Black, of which the Secretary of State has been rather dismissive. Does my hon. Friend agree that for the president of the Royal College of Surgeons to have used language such as “an impending disaster” and to say that these moves would “devastate” medical training and lead to
“dangerous lapses in patient care”,
means that he was making serious criticisms of the proposals, which ought not to be dismissed quite so lightly by the Secretary of State?
Norman Lamb: I am grateful for that intervention, and I agree with my hon. Friend’s comments. Part of the problem in the relationship between the Government and the professions is that the views of the professions are so often dismissed in that way.
Dr. Stoate: The hon. Gentleman is very generous with his time. I would like to quote the British Medical Association:
“The BMA is strongly supportive of the August deadline. Although the 11-year transitional phase for trainees was crucial in ensuring health service delivery was not put at risk unduly, we consider it is now time that junior doctors receive the same level of protection of their health and safety as all other workers in the UK.”
The BMA is in favour of the 48-hour week.
Norman Lamb: Interestingly, when the BMA surveyed its members, they disagreed with the BMA. If we follow the hon. Gentleman’s analysis, we reach the assumption that he is dangerous when providing medical care because, presumably, he is working substantially more than 48 hours in combining this job with that job. He ought to give up his second job on the basis of his analysis of the risks of excessive working hours. There is a great hypocrisy in this place and elsewhere—all of us, by and large, work substantially more than 48 hours a week.
Angus Robertson: On hypocrisy, will the hon. Gentleman allow me?
Norman Lamb: I will give way, because the man is an expert in it. [Hon. Members: “Oh!”]
Mr. Deputy Speaker (Sir Michael Lord): Order. Before the hon. Gentleman intervenes, I should say that “hypocrisy” is not a word we like to bandy about in the Chamber.
Angus Robertson: I am grateful to the spokesman for the Liberal Democrats for taking an intervention on this point, because he will be able to clarify the concerns echoed by those of all other parties who have spoken this evening. Why is it, when we have all shared concerns about retained firefighters and the problems that getting rid of the opt-out would cause, that the only Liberal Democrat Member of the European Parliament from Scotland voted to get rid of the opt-out? Please could the hon. Gentleman take this opportunity to explain why. Did his colleague disagree with the policy or did she just press the wrong button?
Norman Lamb: The hon. Gentleman appears to be stuck in a groove—he has repeated himself rather a lot on that point. There are always occasions when people do not vote with their party. I suspect that he will even find that in his Stalinist party in Scotland.
Norman Lamb: The Secretary of State had enough problems with his own MEPs, and I am sure that he will enlighten us as to why so many Labour MEPs voted to end the opt-out, contrary to his Government’s wishes.
Alan Johnson: I was going back to much less contentious territory, thank you very much. I gave three reasons why I was against the proposal of the Royal College of Surgeons that we should seek a sectoral derogation for a 65 to 70-hour week. I also said that we are working with all the royal colleges and listening to them intently. Is the hon. Gentleman now saying that it is Liberal Democrat policy to support the Royal College of Surgeons in its efforts to get a 65 to 70-hour sectoral opt-out?
Norman Lamb: No, I am not saying that. The point that I made earlier, which the Secretary of State might not have heard clearly enough, is that he appeared to dismiss the concerns that have been expressed by the Royal College of Surgeons and the Royal College of Physicians about the risks to patient care. He shakes his head in a rather dismissive way. Will he listen to those concerns? We all want him to acknowledge that he should do that. Does he wish to intervene to confirm that he will?
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