Memorandum by the Royal College of Obstetricians
and Gynaecologists (RCOG)
1. INTRODUCTION
1.1 The Royal College of Obstetricians and
Gynaecologists is a registered charity (no 213280) and is independent
of the State and the National Health Service. Most obstetricians
and gynaecologists in the UK work within the NHS, however, so
that the standards set by the College have a major influence upon
the good health, treatment and prevention of illness of women
and babies in all sections of the community. A major role of the
College is in providing postgraduate medical education, both for
those training to become specialists in the discipline and for
the continuing professional development of established specialists.
The College has over 4,000 Fellows (FRCOG) and Members (MRCOG)
working in the British Isles and approximately 4,500 working overseas.
In addition, the Faculty of Family Planning and Reproductive Health
Care, based in the College, has 10,500 members.
1.2 The College is pleased that the Sub-Committee
has decided to hold an inquiry into aspects of the European Working
Time Directive because, in common with other medical bodies, it
believes that the Directive will be difficult to implement at
present. Nevertheless, the College believes that the principles
set out in the Directive are appropriate for the safe working
of doctors and that it therefore has important implications for
the safe management of patients in the future.
1.3 The major difficulty relates to the
regulations surrounding the work of junior doctors, especially
in the light of the rulings of the European Court of Justice in
the SiMAP and Jaeger cases. While these rulings
will create problems for most hospital doctors, there will be
particular difficulties for the specialties of obstetrics, paediatrics
and anaesthetics, where there is need for the presence day and
night of doctors with specialty-specific skills. A working party
has been set up at the request of the Department of Health to
address the problems for the provision of maternity services and
its terms of reference are provided as Annex A.
1.4 In the remainder of this document, the
College will comment specifically on the four areas of particular
interest to the Sub-Committee.
2. REFERENCE
PERIODS
2.1 The College believes that the reference
period should be no greater than 26 weeks. This is of particular
importance to junior doctors who are required to rotate through
a series of training posts in order to obtain a breadth of clinical
experience. Conventionally, training posts are occupied for periods
of six months or multiples of six months. A longer reference period
could result in exploitation in a particularly busy post during
part of a rotation followed by an appointment to a relatively
quiet post in order to render the entire period compliant with
the regulations. Such arrangements are unlikely to be good either
for patient safety or for successful training.
2.2 In relation to senior doctors, for whom
such rotations do not apply, the College has no view about the
optimal duration of the reference period.
3. USE OF
THE INDIVIDUAL
OPT-OUT
3.1 The College is in favour of permitting
doctors to opt out of the restrictions imposed by the Directive,
provided that they do so voluntarily and that failure to opt out
cannot be used to their detriment by their employers.
3.2 In the case of junior doctors, however,
the College feels that it could be difficult for a trainee to
resist subtle pressures exerted by a forceful trainer or employer.
The College therefore has significant reservations about the use
of the individual opt-out by these doctors.
4. THE DEFINITION
OF WORKING
TIME
4.1 Preliminary data from a survey carried
out by this College suggest that 15 per cent of junior doctors
are currently working more than 56 hours per week, that 40 per
cent are working 56 hours and that 22 per cent are working between
49 and 55 hours per week. However, most of the rotas in which
these doctors are working at present are not compliant with the
requirements of the Directive. Several of those which are compliant
involve junior doctors working full shifts in groups of six or
seven, an arrangement which tends to be very inflexible and is
not popular. Furthermore, there is genuine concern that service
work of this intensity may seriously impede supervised training.
4.2 The Hospital at Night initiative undertaken
by the Department of Health has successfully demonstrated that
it is possible to use cross-cover arrangements involving teams
of doctors and others with generic skills in order to reduce the
numbers of junior doctors resident overnight. The survey also
showed, however, that in relation to obstetrics and paediatrics
there was always a need for a doctor with special skills to be
present in the hospital throughout the 24 hours so that cover
by others was not a realistic option. This College is therefore
in the process of defining explicitly the skills required by a
resident obstetrician. We are also identifying examples of good
practice some of which necessitate consultants to be resident
in hospital without experienced junior staff. Arrangements such
as these can be expensive, however, and may make it difficult
to provide appropriate senior cover for routine daytime sessions.
Finally, there is clear evidence that consultant obstetric units
in many parts of the country are being replaced by midwifery units
which do not have direct consultant cover. The long-term consequences
of this process are uncertain.
5. COMPATIBILITY
BETWEEN WORK
AND FAMILY
LIFE
5.1 Obstetrics is a busy and demanding specialty
but one which has a special appeal for women doctors. There has
been a steady increase in the proportion of female trainees in
the specialty. Currently about 25 per cent of consultants in the
obstetrics and gynaecology are women. However more than 50 per
cent of specialist registrars are female and the proportion is
rising annually. This College has done much to encourage women
to remain in the specialty. We were one of the first Colleges
to introduce flexible training and first appointed a flexible
training adviser some fifteen years ago. Currently between 20
and 25 per cent of our trainees are in flexible training posts.
5.2 Flexible training can be very satisfactory
for young women who have family commitments. However, the high
proportion of part-time trainees can create other problems, especially
if shift working is introduced without flexibility. Furthermore,
the duration of training has to be extended for these trainees
and this can compromise calculations for workforce planning.
6. CONCLUSIONS
6.1 The College is generally supportive
of the principles underlying the European Union Working Time Directive.
6.2 The restrictions imposed by the rulings
of the European Court of Justice in the SiMAP and Jaeger
cases will almost certainly make it impossible for all hospitals
to comply with the Directive in the near future.
6.3 Longer term solutions for obstetrics
must involve more skilled doctors, possibly consultants, living
in hospital when on call. It is likely that there will also be
fewer consultant obstetric units. What is essential is to maintain
safety for women and their babies during the difficult transitional
period.
23 February 2004
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