Memorandum by the Royal College of Physicians,
London
The recently launched European Commission Consultation[12]
on the EWTD concentrates on five main issues: (1) the length of
reference periods; (2) conditions for the application of the opt-out;
(3) the definition of working time; (4) measures to improve the
balance between work and family life; and (5) how to find the
best balance of these measures. This evidence is based upon recent
research and debate at the Royal College of Physicians, London
(RCP).
1. SUMMARY
1.1 The RCP fully supports the main thrust
and intention of the European Working Time Directive (EWTD).
1.2 We applaud the ongoing efforts of Government,
NHS managers and clinicians to implement EWTD. It is clear that
the service's state of readiness has improved over the last year
and RCP will continue to support implementation efforts at both
a national and local level.
1.3 Nonetheless full compliance with the
Directive throughout the NHS is highly improbable by the August
2004 deadline.
1.4 We remain concerned that—in its
present shape and form—compliance will have serious long-term
effects for continuity of care, patient safety, and the education
and training of doctors.
1.5 If full-shift working is imposed on
all residential junior doctors in August 2004, there are presently
not enough trained doctors in all the acute specialties to maintain
safe levels of patient care in every hospital.
1.6 It is clear that the SiMAP and
Jaeger judgments in particular have created huge difficulties
for hospitals throughout Europe. In the current scenario where
postponement of implementation of the EWTD is not legally possible,
urgent clarification of the implications of these judgments and,
particularly, of the definition of "working time" is
needed.
2. REFERENCE
PERIODS
2.1 The RCP feels that the reference period
should be set at 26 weeks, or the period elapsed since starting
in post if that period is less than 26 weeks.
2.2 There are particular problems where
a junior doctor is rotating between posts that have a variable
intensity of work, but it would seem reasonable for less hectic
postings to balance more busy periods, as long as compensation
is achieved within the 26-week period.
3. OPT-OUT
3.1 The RCP has no objection to maintaining
the opt-out for those doctors able to determine their own working
hours. However there are a number of provisions which must be
met if the opt-out remains a part of the legislation.
3.2 Any opt-out must be truly voluntary
and no undue pressure or coercion should be placed on doctors,
particularly those in vulnerable positions, to work outside the
EWTD hours and rest requirements. Under no circumstances should
an opt-out be a necessity for a post, or form part of any contract.
3.3 If the opt-out were to be annulled by
European legislation, consultant involvement in clinical care
may be severely curtailed. The Annual Royal Colleges of Physicians
Manpower Survey reported that in 2002 the average Consultant Physician
in England worked 54.4 hours each week for the NHS[13].
If forced to restrict their work to a maximum 48-hour week, the
number of consultant physicians in England would need to rise
from 6,184 to 7,211—an increase of 16.7 per cent.
3.4 Whilst a maximum 48-hour working week
may be a laudable objective, it is unlikely that there will be
enough consultant physicians in the UK for the next few years.
4. DEFINITION
OF WORKING
TIME
4.1 The impact of the SiMAP and Jaeger
judgments—essentially that resting or even sleeping at hospital
counts as working—on the medical staffing structure of all
hospitals can scarcely be exaggerated. They effectively abolish
on-call rotas for resident doctors, and consign them to shift
work from August 2004. This change to shift work has huge implications
that need to be considered in detail.
4.2 The previous "status quo"—on-call
rotas. These have been the working pattern for virtually all junior
doctors for decades. Teams of 3-5 doctors would manage all acute
medical admissions[14]
over a 24-hour period. In an ideal situation, they worked closely
as a team, developing camaraderie, learning from each other, ensuring
that everyone obtained enough sleep, and maintaining continuity
of patient care. The presence of junior doctors taking a variable
number of hours asleep provided the hospital with a strategic
reserve of expertise to treat patients in an emergency. Problems
arose if trainees were unable to obtain enough—or any—sleep
because of excessive workload, but the New Deal legislation provided
a safeguard by stipulating that they must obtain at least five
hours sleep on 75 per cent of nights.
4.3 The current situation—results from
a 2004 RCP survey
4.3.1 In December 2003-January 2004 we performed
a snapshot survey of acute medical units in hospitals in England
and Wales, and obtained a response rate from senior consultants
at 84 per cent—189 out of 226 hospitals. This has shown
that Specialist Registrars (SpRs) in 47 per cent of acute hospitals
are still working on-call rotas, in contrast to only 7 per cent
of Senior House Officers. All are expected to change to shift
work in August 2004.
4.3.2 Figure 1 in the Appendix shows the
rapid decline in the proportion of hospitals with on-call rotas
for juniors in acute medicine, from virtually 100 per cent in
1996, to the projected 0 per cent later this year when the EWTD
is in place.
4.4 The need for more staff to maintain full-shifts
4.4.1 Traditional on-call rotas for SpRs
required six or seven staff to cover emergencies for one day in
six or seven, whereas 10 staff are needed to maintain a viable
full-shift rota, allowing for prospective cover for leave and
providing time for specialist training. Thus, the switch to full-shifts
necessitates a large expansion in the number of middle-grade doctors.
In a creditable attempt to tackle these problems, the Government
authorised the provision of over 500 more National Training Numbers
for SpRs in acute medical specialties in 2003.
4.4.2 In our survey, 107 (57) per cent of
hospitals had obtained at least one more SpR in 2003, and 75 (40)
per cent had obtained two or more. Unfortunately this rapid expansion
is still insufficient. The histogram (Figure 2 in the appendix)
shows the numbers of middle-grade staff in acute medicine in 189
hospitals. 113 (60 per cent) still do not have the necessary 10
middle-grades for a robust full-shift system. Some propose that
full-shifts can work with only eight staff, but 72 (38 per cent)
of hospitals have less than eight middle-grades.
4.4.3 Thus there are currently insufficient
middle-grade staff in acute medicine in a significant proportion
of British hospitals. Faced with these problems, some hospitals
will use less experienced senior house officers to "act up"
as SpRs. But—even assuming the numbers exist to do this,
such moves are fraught with clinical governance and risk implications.
4.4.4 When respondents were asked whether
they would be able to comply with the EWTD for junior medical
staff in medicine in August 2004, most stated that they would
"definitely" (31 per cent ) or "probably"
(46 per cent ) be able to comply, but 28 (15 per cent ) stated
that they "probably" could not, and 16 (8 per cent )
that they "definitely" could not, comply.
4.5 Other ways of filling the shortfall in
middle-grade cover
4.5.1 There has been a welcome drive to
develop innovative working practices to compensate for the reduction
in medical cover. These have focused on skill mix initiatives
whereby nurses or other staff have undertaken duties of junior
doctors, and cross cover schemes among juniors in different specialties.
The "Hospital at Night" initiative[15]
and the "Out of Hours Medical Team"[16]
have introduced excellent potential improvements in efficiency,
collaboration and multi-disciplinary work—but they do little
to relieve the lack of junior staff—particularly at the
SpR grade.
4.5.2 Our survey revealed that 42 per cent
and 28 per cent respectively of hospitals have introduced nurse
practitioners and health care assistants to help with acute medicine
and, although adjudged successful, 82 per cent of respondents
felt that they will not allow their hospitals to cope with fewer
doctors.
4.6 The situation in other acute specialties,
and across Europe
4.6.1 The human resource problems in providing
safe levels of middle-grade cover for obstetrics, paediatrics,
surgery and anaesthetics are either similar or worse to those
in acute medicine. Again, there may be sufficient experienced
middle-grade staff to manage on-call rotas but insufficient to
cope with the switch to full-shifts.
4.6.2 This is a national problem, and the
Government has stated to the European Commission that we require
between 6,250 and 12,550 more doctors to comply with the EWTD.[17]
4.6.3 This mirrors the situations in Germany
and Netherlands described in the consultation document (page 20).
The German estimate of the increase in doctors is 15,000-27,000,
and that of the Netherlands 10,000 more. As the consultation document
reports, all these countries agree that even if funds were available,
it "would be impossible (sic) in practice because of the
current lack of candidates with the necessary training to take
on these jobs".
4.6.4 The problems may nevertheless be worse
in the UK because we have a lower ratio of doctors per head of
population, with only 1.7/1,000 compared with the European average
of 3.4.
4.7 Safe full compliance with the EWTD in
August 2004
4.7.1 Government has made clear that implementation
of EWTD is not optional. But, based on our evidence, we remain
concerned that—in its present shape and form—full
compliance will not be achieved without detrimental effects on
continuity of care, patient safety, and medical education and
training.
4.8 The need to redefine working time to counter
the SiMAP and Jaeger judgments
4.8.1 Most of these tumultuous changes arise
from the SiMAP and Jaeger judgments on the definition
of working time, rather than the EWTD itself, whose aims we enthusiastically
support.
4.8.2 The RCP believes that urgent clarification
of the implications of these judgments is needed and a better
definition of "working time". We support the alternative
common sense and pragmatic view that "sleeping isn't working",
and suggest that this is far more persuasive than the position
adopted by the European Court of Justice. One option would be
for the definition of working time to be left to national governments,
to be interpreted in the light of their own circumstances.
4.9 Other aspects—non-resident on call
and training periods
4.9.1 We recommend that time spent not working
whilst non-resident on call should not be classed as working time
and therefore should be counted as rest for the purposes of the
EWTD. However, we advise that all time spent working (including
telephone calls) whilst non-resident on call should count as working
time—from the point of interruption to the time that the
individual returns to rest. We believe that formal education and
study should be counted as part of the normal working week for
the purposes of the EWTD.
5. EWTD AND WORK/LIFE
BALANCE
5.1 The EWTD is Health and Safety legislation,
designed to benefit employees and, in the case of medicine, their
patients.
5.2 Unfortunately in practice, it may have
an unexpectedly adverse impact on work/life balance, because of
the imposition of shift working patterns.
5.3 For most junior doctors in residential
specialities this means switching to full-shifts which include
blocks of nights—either taken as seven serial nights, or
as blocks of four and three nights taken twice as frequently.
5.4 Views of SpRs on the EWTD changes
5.4.1 A questionnaire was sent by the RCP
in October 2002 to all SpRs in acute medicine throughout the UK,
and replies received from 990 (54 per cent ).[18]
They were asked which type of working pattern they preferred,
and 76 per cent gave the answer "on-call rota" or "24-hour
partial shift" (a similar pattern), whereas only 6 per cent
elected for "full-shift". When asked, "Do you welcome
or oppose the move to full-shift for all resident SpRs?"
74 per cent indicated that they "strongly opposed" or
"opposed" it, and only 11 per cent "welcomed"
or "strongly welcomed" it. They were asked what impact
the move to full-shifts would have on their quality of life and
75 per cent indicated that it would "seriously worsen"
or "worsen" it—but only 13 per cent thought that
it would "improve" it.
5.5 Lessons from the 2002 RCP SpR survey
5.5.1 This large survey, from almost 1,000
SpRs, illustrates their deep concern about EWTD changes and impact
on their quality of life. Most SpRs are aged between 28 and 36,
most are in relationships—usually with other doctors—and
almost half are parents. They must rotate between different hospitals,
and many have long journeys.
5.5.2 Weeks of night duties—9pm to
10 am for seven consecutive nights (a total of 91 hours in a week)—may
be acceptable to younger trainees aged 24 to 27, but are profoundly
unpopular among many SpRs.
5.5.4 The RCP is concerned that obligatory
full-shifts for all trainees in acute specialties until the age
of 35 may therefore have a serious impact on recruitment into
acute medicine. There is already some evidence to suggest that
there has been a failure to fill National Training Numbers in
medical specialties such as endocrinology and renal medicine,
which were previously highly competitive. Clinicians are likely
to increasingly choose to work in specialties with a more attractive
work/life balance, to the detriment of acute medicine. It may
prove impossible to staff acute services in the near future if
these trends continue.
12 http://europa.eu.int/comm/employment_social/consultation_en.html Back
13
Census of Consultant Physicians in the UK, 2002, published 2003. Back
14
Acute medicine includes the specialities of General (Internal)
Medicine, Geriatric Medicine, Cardiology, Gastroenterology, Thoracic
Medicine, Endocrinology, Nephrology, Rheumatology etc. Back
15
Hospital at Night, DoH (http://www.doh.gov.uk/configuringhospitals/hosp-night-intro.htm). Back
16
Out of Hours Medical Team (http://www.aomrc.org.uk/pdfs/doh.pdf). Back
17
p.20 http://europa.eu.int/comm/employment_social/consultation_en.html Back
18
RCP Surveys 2002 (http://www.rcplondon.ac.uk/pubs/books/EWTD/index.asp). Back
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