Working Time Directive Taskforce

Royal College of Physicians of Edinburgh Response to the implementation of the working time directive – and its impact on the NHS and health professionals Call for evidence

The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the call for evidence on the implementation of the working time directive and its impact on the NHS and health professionals. The College represents Fellows and Members across the UK, with around 50% of our UK membership working in the NHS in England.

Summary

The College feels that the European Working Time Directive (EWTD) has had unintended adverse consequences on both training and service. While the improvement in trainees’ work / life balance has been positive[i], it has also had detrimental effects on continuity and quality of patient care and the training of junior doctors[ii].

Have you or your organisation encountered any problems relating to the Working Time Regulations and, if so, around what issue in particular?

Training

Some of the particular issues that have been brought to the College’s attention around training include:

• Trainees feel focus is on service rather than training, and that their training and quality of life is badly disrupted through difficult rota patterns. Employers’ threats of imposing shifts may be stifling complaints.
• Gaps in the rotas due to vacancies, maternity leaves and sickness add to the pressure on trainees and limiting teaching opportunities further. Trainees felt under pressure to stay beyond hours and/or support their own locums. Some trainees are happy to stay on – recognising the training and patient safety issues.
• There are even less opportunities for consultants to work with their allocated trainees, limiting teaching, assessment and mentoring opportunities. Much concern has been expressed about inadequately assessed/trained consultants in the future and worries about erosion of professionalism and work ethic.
• Rota patterns to achieve 48 hours have resulted in trainees missing outpatient clinics, teaching lists and ward rounds – this was of particular concern for Specialty Registrars who were missing specialty teaching sessions (elective lists, clinics, procedure sessions etc) due to covering wards or on call duties or rostered off duty.
• Planning is badly disrupted by trainees being reallocated to cover emergency call and ward duties at short notice, wasting training opportunities set up for them.

These experiences are mirrored in the literature review of the Impact of the Working Time Regulations on Medical Education and Training commissioned by the GMC, which states “doctors’ perceptions of the educational impact of restrictions are largely negative”[iii]; and in typical comments taken from recent GMC National Surveys of Trainers such as:

“Please can the GMC take a lead in articulating the pressures on training created by EWTD.   This is the greatest threat to our professional integrity over the next 10 years and it worries  me hugely.”[iv]

 “EWTD and full shift rota’s have ruined the junior doctor experience to the detriment of their training and hence to their experience of “continuity of care[v]”

The GMC survey also indicates that one in five trainees do not feel confident they are acquiring the competences needed at their particular stage of training[vi].

The most recently published census data of physicians in the UK found that over 60% felt that the EWTD has made quality of training “worse” or “much worse”[vii].

The final report for the GMC into The Impact of the Working Time Regulations on Medical Education and Training concluded that:

“the Temple Review urged that medical education and training make ‘every moment count’, meaning that medical education should be embedded in medical practice, and that service delivery should be aware of its educational component. This is not yet the case for many trainees, and there is an increasing separation between work and education that may be adding new stressors to the trainee population. …The GMC has power as the regulator of medical education, and may be able to redress the balance of education and service through its role in quality assurance. Education and training should be placed at the heart of service delivery. Education is not seen as at the expense of patient care, but as a means of maintaining it.[viii]”

Patient care

The College has been made aware of concerns around poor continuity of care, largely caused by difficult shift patterns and multiple handovers causing trainees concerns about lost learning opportunities and reduced continuity of patient care.

The most recently published census data of physicians in the UK found that 59% felt that the EWTD has made patient care “worse” or “much worse”[ix]

What have you or your organisation been able to do to solve these problems?

EWTD is primarily a legislative issue and as such the College has highlighted these problems and suggested solutions to both UK and Scottish Governments through various means including consultation responses and meetings with Ministers.

What more could be done to solve these problems?

It is important that, particularly in the area of medical and surgical training, the EWTD is not required to be implemented rigidly in member states, such as the UK, where there is clear evidence that such a Directive interferes with the quality of training and subsequent safety of service provision.

We would also suggest that within the existing framework action could be taken around intelligent rota design to foster better training and work/life balance for doctors whilst maintaining excellent standards of patient care and ensuring that physicianly medicine remains an attractive career option.

Is there specific evidence (such as publications or studies) you would highlight to the taskforce?

The Impact of the Working Time Regulations on Medical Education and Training: Literature Review:  A Report for the GMC (August 2012)

The Impact of the Working Time Regulations on Medical Education and Training: Final Report on Primary Research: A Report for the GMC (August 2012)

2011 Census of consultant physicians and medical registrars in the UK: The Federation of the Royal Colleges of Physicians of the United Kingdom (published 2013), in particular pages 269-271

GMC National Training Survey:

2011 http://www.gmc-uk.org/National_Trainer_survey_2011_v5.pdf_48076220.pdf and http://www.gmc-uk.org/NTS_trainee_survey_2011.pdf_45270429.pdf

RCPE Charter for Medical Training http://www.rcpe.ac.uk/sites/default/files/files/rcpe-charter-for-medical-training_0.pdf

Are there any examples of ways in which the Working Time Directive has been successfully implemented that you would like to highlight?

Intelligent rota design and electronic rostering systems can improve the challenge of creating on call rotas for consultants and trainees that improve the continuity of the team for patient care and training benefit. Regretfully these are not yet universally available and of themselves will not address the overall reduction in training time which is of great concern to all.