Memorandum by the National Specialised
Commissioning Team
IMPLICATIONS OF
THE EUROPEAN
WORKING TIME
DIRECTIVE (EWTD) FOR
ORGAN TRANSPLANTATION
SERVICES
The EU Commission's Communication makes no mention
of the potential impact of the European Working Time Directive
(EWTD) on the availability of donor organs and transplantation.
Full implementation of EWTD and strict compliance threaten the
viability of heart and lung transplant services in England.
EWTD compliance is particularly difficult for
heart and lung transplantation because:
— It is a 24-hour a day service
requiring two rotas: one for retrieval of donor organs and one
for implantation (ie transplanting the organ).
— Transplants usually occur at
night because hearts and lungs are the last donor organs to be
removed.
— The ischaemic time that can
safely elapse before transplantation (ie the time between removing
and transplanting the donor organ) is shorter for heart and lung
than for kidney and liver.
— Implantation needs a consultant
transplant surgeon available at all times and consultants also
have a role in training retrieval teams.
— From notification that an organ
is available to completion of the transplant takes about 12 hours.
— The availability of suitable
donor organs is unpredictable, which limits the potential for
planning transplant work to fit in with other commitments.
— All heart and lung transplant
surgeons carry out their transplant work in addition to the same
general cardiothoracic surgery workload as their non-transplant
colleagues.
— Strict compliance with compensatory
rest would lead to cancellation of theatre lists for non-transplant
work, delays for patients and difficulties meeting targets.
In late 2003, the National Specialist Commissioning
Advisory Group (now called the National Commissioning Group),
which is the body that commissions the national heart, lung, liver
and pancreas transplant services in England, carried out a survey
on EWTD compliance at the heart and lung transplant centres in
England. The survey report drew the following conclusions:
— Few of the current heart and
lung transplant rotas were compliant with the EWTD.
— The supply of potential new
recruits (particularly transplant surgeons) was not enough to
meet the demands of compliance.
— Even if additional staff could
be recruited, there were serious concerns that this would dilute
training opportunities and reduce surgery volumes thus impairing
maintenance of expertise.
— Strict adherence to the EWTD
in transplant surgery would have an opportunity cost for non-transplant
cardiothoracic surgery.
— The challenge of EWTD was particularly
marked for paediatric heart and lung transplantation.
In 2004, the National Specialist Commissioning
Advisory Group (NSCAG) explored the implications of EWTD for heart
and lung transplantation further through computer modelling of
consultant rotas to show what was required to achieve compliance.[2]
The attached Appendix gives examples of this modelling.
The first example shows a compliant implantation
rota for nine consultant transplant surgeons. It raises
the following questions. Would there be enough daytime transplant-related
and other non-transplant work to make full use of the number of
surgeons available? Would there be a sufficient volume of surgery
for individual surgeons to maintain their skills and experience?
Such a rota might be feasible in a centre covering a larger catchment
population than that of any of the existing transplant centres,
but reducing the number of transplant centres was ruled out by
Ministers in 2002.
The second example shows a compliant implantation
rota for four consultant transplant surgeons that ensures
immediate compensatory rest on the day after carrying out a transplant
at night. It shows how many weekdays would have to be taken off
to ensure compliance, thus reducing greatly the availability of
consultants to fulfil their non-transplant work. Such a rota would
only be feasible if surgeons were to do nothing other than transplant
work.
In 2004, NSCAG also considered a number of options
to address the threat presented by EWTD. It concluded that none
of these lay within its power or that of the heart and lung transplant
centres, and it decided to keep the situation under review.
Although this fully worked example refers to
heart and lung transplantation, similar issues apply in other
transplant services such as liver, pancreas and small bowel.
In summary, strict compliance
with the EWTD is incompatible with a viable transplant service.
The EU Commission should acknowledge this and amend the EWTD accordingly
to avoid transplantation ceasing to be viable in countries that
enforce compliance and the law being broken in countries that
do not.
21 September 2007
2 The modelling package was the Doctors' Rostering
System (London and South East Regional Action Team). Back
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