Memorandum by The Royal College of Surgeons
Edinburgh
Firstly, as a chairman of the Joint Committee
of Higher Surgical Training and, more recently as President of
the Royal College of Surgeons of Edinburgh, I have been responsible
for preparing documents regarding the concerns of all the surgical
Royal Colleges and the Specialty Associations about the implications
for training imposed by the European Working Time Directive. I
enclose copies of a response from the Joint Committee on Higher
Surgical Training and from the Royal College of Surgeons of Edinburgh
in the hope that this will be helpful to your Sub-Committee. If
you would like any further assistance in this matter, please let
me know.
INTRODUCTION
The Royal College of Surgeons of Edinburgh is
a registered charity and is independent of the State and the National
Health Service. It is one of the oldest medical institutions in
existence and will celebrate its Quincentenary beginning on 1
July 2005. Throughout its history, it has been intimately involved
in the education, training and assessment of surgeons. Over the
last 20-25 years, many of these activities have been undertaken
in collaboration with our sister Colleges and with the Specialty
Surgical Associations mainly through the aegis of the Joint Committee
on Higher Surgical Training; the Joint Committee on Intercollegiate
Examinations and the Senate of Surgery of Great Britain and Ireland.
The College has approximately 16,000 Members
and Fellows situated in over 90 countries in the world. However,
in terms of the European Union Working Time Directive, it is important
to emphasise that the College has 9,528 Members and Fellows in
Great Britain and Ireland of whom 1,546 work in Scotland and 7,460
work in England and Wales of which number 6,500 approximately
are affiliated only to this College. Thus we have a responsibility
for these doctors throughout the United Kingdom.
The Royal College of Surgeons of Edinburgh has
been involved with the Joint Committee on Higher Surgical Training
on addressing the problem that current standards of training and,
therefore, current standards of patient care, are maintained despite
many new pressures one of which is compliance with the European
Union Working Time Directive. The College recognises that the
legislation applies also to established consultants. The extent
of the latter problem will only become clear when results of negotiations
of the new Consultant Contract have been completed. However, it
is believed that there will be a significant shortfall in the
number of consultants required to meet these changes.
The College and, indeed, all the surgical Colleges
and Specialty Associations are most concerned about the influence
of the Directive on training. The aim of training is to produce
an individual with knowledge and skills to allow practice within
a defined clinical framework working as a member of a consultant
team. It is also important to ensure that the individual has reached
a stage of competence such that he or she feels comfortable and
confident about the duties expected of them.
In common with many other Colleges, the Royal
College of Surgeons of Edinburgh believe that with current levels
of staffing and with the current disparity in staff numbers between
larger teaching and smaller District General Hospitals, that it
will be very difficult to introduce compliant rotas which do not
have an adverse effect on surgical training. The additional pressures
resulting from the SiMAP and Jaeger cases together
with confusion as to whether educational activities should be
included within the Working Time or not simply compounds the problem.
The College recognises that simple calculations
of reduction in hours of training which would suggest that trainees
working under the Directive will have only 6,000-8,000 hours of
training as compared to 30,000 previously are unhelpful. It is
the quality of training and the efficient use of training time,
which must be emphasised. It is clear that a number of successful
and compliant rotas have been established within the surgical
specialities and experience from both surgical and medical units
suggest that an absolute minimum of eight individuals is required
and that 10 is desirable. It will be clear from the numbers involved
that only larger institutions will be compliant. It must also
be realised that this places an additional burden on the consultant
and may interfere with their compliance to regulations.
RECOMMENDATIONS
1. Training must be given a very high priority
if standards of patient care are to be maintained for the foreseeable
future. The importance of trainers must be recognised and appropriate
resources provided both as regards time and money. Training and
education must be part of individual job plans and must be included
in the new Consultant Contract.
2. The curriculum based training programme
which is now being piloted on behalf of all the surgical Colleges
through the aegis of the Joint Committee on Higher Surgical Training
must be introduced as soon as practicable. This will allow a move
away from fixed terms of training to a system of progression based
on assessed competence through a modular framework.
3. Inappropriate tasks must be identified
and excluded from the work plans of trainees and trainers so that
the maximum available opportunities for training are properly
used. This will involve a blurring of barriers between different
healthcare professionals and this must be managed sensitively
if shortages in other areas of healthcare are to be avoided.
4. It is recognised that all trainees learn
by helping to deliver service needs. Greater consideration must
be made to those times of the day when clinical exposure and training
opportunities are minimal. In many surgical specialties, there
are few opportunities of training between 10 pm and 8 am and this
should be investigated thoroughly on a specialty specific basis.
QUESTIONS AND
ANSWERS
1. What does the European Working Time Directive
actually mean?
A: For a Consultant a maximum of 48 hours
working week; 11 hours rest in 24 hours; and 24 hours rest in
each seven day period or 48 hours rest in 14 days.
For juniors a 58 hours maximum from 1 August
2004.
A 56 hour maximum from 1 August 2007.
A 48 hour maximum from 1 August 2009.
All rest requirements to apply from 1 August
2004.
2. What are the rest requirements?
A: A trainee doctor cannot work continuously
for more than 13 hours without a minimum period of 11 hours of
rest between duty periods.
A trainee doctor may not work more than 58 hours
per week which, in the UK, means 56 hours of actual work averaged
over a 26 week period.
A trainee is working if required to be in
the hospital whether awake or asleep.
3. What about educational activities?
A: There is considerable confusion about
whether educational activities are included in the working week
or not. A legal opinion obtained by the Royal College of Surgeons
in Ireland based on European law suggests that, if the educational
activity is voluntary, then it will not count towards maximum
hours of work. In the United Kingdom, this area is much greyer
and it has been suggested that only a legal challenge would allow
a definitive position to be reached. Most other professions exclude
educational activities from the working week and it is hoped that
a definitive legal opinion can be obtained in the near future.
4. What are the implications for training?
A: It is clear that the actual number of
hours of training will be very significantly reduced, probably
by 50 per cent of current standards. However, the College recognises
that quality of training is more important than simple hours and
it is vital that all available training time is used as effectively
and efficiently as possible.
It seems that a minimum of eight to 10 individuals
are required for a compliant rota and there is some evidence from
some centres that training can continue to the present high standards
within the confines of the Directive. This has significant impact
on the consultant who, at present, is able to opt-out from the
48 hour ruling but will not be able to do so in the future.
5. Do all surgical trainees have to be available
to provide 24-hour cover within a hospital?
A: In many but not all surgical specialities
very little surgery is actually done between 10.00 pm and 8.00
am. In those specialties, it would be possible to avoid having
an SpR on call for that period provided there is adequate cover
for problems arising within the hospital during that time and
provided appropriate surgical cover was available to meet those
demands.
The concept of a team available to cover night
time emergencies has been elaborated by the Royal College of Physicians
of London. It must be recognised that, if there is a surgical
emergency, this will be dealt with by the consultant on-call.
Clearly, this has implications as regards numbers of consultants
who are available and the necessity for protected time off, if
sleep is disturbed. These provisions are ensured in the Directive.
It also means that maximum use of operating facilities should
be ensured between 8.00 am and 10.00 pm.
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