Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Shift working is an inevitable consequence of the European Working Time Directive
- Andrew G Rowland (10 February 2003)
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Significant effect of shift systems on surgical trainees
- Dean A Harris, Andrew G. Radcliffe consultant surgeon and Jared Torkington consultant surgeon (28 February 2003)
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Can we ever shift back to on-calls?
- ben messer (19 March 2003)
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Shift work is here to stay. 24 hours on-call is a system of the past.
- Andrew G Rowland (3 April 2003)
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House officer's personal view of shift and rota systems.
- Aman Chandra (11 June 2003)
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Andrew G Rowland, Senior House Officer in Paediatrics Royal Manchester Children's Hospital, Hospital Road, Pendlebury, Manchester, M27 4HA, UK
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EDITOR: Aitken and Paice have shown that trainees’ attitudes to shift work depend on grade and specialty.(1) With the implementation of the European Working Time Directive in August 2004 (2), working patterns for many doctors in training will have to radically change. The organisation of such changes will present a major challenge to NHS Trusts and the Department of Health. The European Working Time Directive will enforce stringent requirements on doctors and employing trusts. As part of health and safety legislation, its implementation cannot be avoided. From August 2004 there will be a reduction in the maximum number of hours worked by doctors in training to 58 per week; from 2009 this will be reduced further to 48. Furthermore the directive spells out stringent rest requirements so that continuous working is limited to no more than 13 hours in 24. Given the SiMAP judgement of the European Court of Justice, all hours spent on the hospital premises whilst on call will be classed as work.(3) This will have major implications for the working patterns of doctors in training. Aitken and Paice(1) discussed some of the negative attitudes to shift working patterns including a perceived disruption to social or family life as well as concerns about training experience especially in some of the surgical specialties. Apart from specialties in which on call commitments are extremely low, shift-based working patterns will be an inevitable consequence of the implementation of the EU Working Time Directive and planning needs to take place at an early stage to deal with this reality. The reduction in the number of hours doctors are allowed to work will mean that either more doctors need to be recruited per trust or that tasks normally undertaken by medically qualified staff must be redistributed to other staff and that new healthcare practitioner roles may need to be developed to take on this work. Without doubt, many specialities require on-site 24 hour availability of medical staff, however any shift-based working patterns will reduce the availability of junior medical staff during the normal working day. Changing working patterns within any organisation will take time and until this is achieved the recruitment of more doctors may be the only way in which to ensure adequate day-time cover as well as compliance with the stringent requirements of the EU Working Time Directive. The Department of Health and NHS Trusts have little over one year to ensure that robust mechanisms exist to deal with the changing working patterns of doctors in training and that these changes are approved by Royal Colleges and Postgraduate Deans as well as the junior medical staff involved. The time to act is now to implement a system to deliver a high quality, cost-effective method of patient care before the legal reality of the EU Working Time Directive is upon us and it is too late to respond, other than in a court of law. 1. Aikten M, Paice E. Trainees’ attitudes to shift work depend on grade and specialty. BMJ 2003;326:48 (4 January 2003) 2. http://www.doh.gov.uk/workingtime/ 3. http://www.doh.gov.uk/workingtime/simap.htm Competing interests: AR is the Junior Doctor Representative for Royal Manchester Children's Hospital and is involved in negotiation with the trust concerning changing working patterns. Opinions expressed are entriely personal. |
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Dean A Harris, Specialist registrar Cardiff and Vale NHS Trust, Cardiff CF14 4XN, Andrew G. Radcliffe consultant surgeon and Jared Torkington consultant surgeon
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EDITOR- Aitken and Paice(1) reported the expectations that trainees have towards working shift patterns to achieve EWTD compliance. We have surveyed the impact on surgical training after the implementation of a partial shift system. In May 2002, general surgery senior house officers in Cardiff and Vale NHS Trust had their working pattern changed from a traditional on-call rota to a partial shift system, thereby limiting their working week to 56 hours. We evaluated the number of consultant-led clinics and the number of elective operating lists that each trainee was able to attend in the three month periods before and after the change. These are the two main opportunities for surgical trainees to interact with their consultant trainers. We found that as a result of partial shifts, the mean number of clinics that the trainee was able to attend fell by 52% (14.7 to 7, p=0.006). Attendance at elective operating sessions fell by 42% (18.6 lists to 10.8, p=0.006). When questioned, trainees expressed great dissatisfaction with the level of training they were receiving. This is the sad situation that the surgical trainees in Aitken and Paice’s survey would face, should partial shifts be hurried through in south London. They are clearly alert to this threat already; 74% of them would be opposed to working shift patterns, primarily because of the impact on experience (63%), and secondarily, because of impact on family life (25%). It is noteworthy that the trainees in medicine, paediatrics, anaesthesia, emergency medicine and obstetrics would welcome the introduction of shifts. Junior surgeons have different training needs and requirements to their colleagues; it is vital that we don’t end up with the same ‘package’. The Directive is EU law and it is too late to oppose its establishment in 2004. Its introduction is untimely, with reports that UK medical training can no longer be considered the best in the world (2), wholly as a result of the continuing reduction in trainees’ hours. Elsewhere, nearly 60% of consultants interviewed would be unhappy for a newly appointed Calman consultant to operate on them (3). EWTD has the potential to further undermine an already beleaguered training system. It is up to us, and the professional bodies that represent us, to decide whether we seize this as an opportunity to overhaul medical training, or whether we simply respond to its demands, thereby putting training after service provision. References 1. Aitken M, Paice E. Trainees’ attitudes to shift work depend on grade and speciality (letter). Br Med J 2003;326:48. 2. UK training ‘no longer best’. Hospital Doctor 16th Jan 2003, p.4. 3. Morris Stiff GJ, Clarke D, Torkington J, et al. Training in the Calman era: what consultants say. Ann R Coll Surg Engl(Suppl) 2002;84:345-7. Competing interests: None declared |
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ben messer, sho renal medicine freeman road hospital, newcastle
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EDITOR-I read with great interest the neat study undertaken by Aitken and Paice. Obviously the attitude towards shift work is highly dependent upon speciality and grade as well as obligations outside medicine. Clearly training needs and family committments raise important objections to shift work. There are, however, other equally compelling arguements against the shift system and I wonder whether the on-call system was so unworkable to doctors and so detrimental to patient care to deem these arguements irrelevant. The primary flaw with the shift system is that it necessarily leaves the ward with one, two or three fewer doctors during normal working hours (the exact number will depend on the shift pattern and the number of doctors working the particular rota). Shift work therefore raises concerns regarding the staffing of wards and outpatient clinics and continuity of care which has implications for both the care of patients and doctors' training. It is the experience of many consultants that clinics have had to be trimmed and that a different junior doctor is present on each ward round with varying knowledge of the patients he or she is about to present. Furthermore, the intensity of the working day is increased by always having at least one doctor fewer on duty. Additionally, few junior doctors will not have experienced difficulties planning and obtaining annual and study leave since the introduction of this system. Two issues remain to be resolved. Firstly, are there health implications for those working a shift pattern and are they more than in those working an on-call pattern? Secondly and most important of all, what are the implications to patient care of a shift system? Certainly continuity of care is reduced. However, is a doctor thrown into a one off week of nights with little or no time to adjust their sleep pattern so much more competent than one woken from slumber after twenty hours at work to compensate for the objections to shift work which make it unpalatable to so many junior doctors? The answer to the working hours problem is of course, more doctors, but how best to use those doctors; giving everyone more days off on a shift system or decreasing the frequency of on-call committments? Answers on a postcard if your rota has allowed you a holiday! Competing interests: None declared |
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Andrew G Rowland, Senior House Officer in Paediatrics Royal Manchester Children's Hospital, Hospital Road, Pendlebury, Manchester M27 4HA
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Messer wonders whether we could ever shift back to on call systems of working. The simple answer to this point, for many specialties, is NO! Implementation of the European Working Time Directive (EWTD) is a non -negotiable part of Health and Safety legislation. In fact its implementation for junior doctors in training is later than that of other professions. The EWTD sets clear limits on the amount of work allowed during any 24 hour period, and also the duration of rest required between these work periods. For many specialities these limits mean that 24 hour resident on- call systems are rotas of the past. Such working patterns are likely to contravene the forthcoming legislation leaving offending trusts open to investigation and potential prosecution by the Health and Safety Executive. Shift based working patterns do reduce the number of doctors available during the normal working day. However, the EWTD limits have been available for some time now. It is up to individual trusts to look at staffing levels and service provision to ensure that, when these guidelines are implemented in August 2004, sufficient doctors are available to cover the service needs of the establishment as well as provide adequate training of the doctors employed. In the short term this may involve increasing the number of doctors employed. In the longer term attention should be given to re-designing service provision in a geographical area and looking at ways trusts can provide an acceptable service to their patients whilst still complying with essential health and safety rulings. Continuity of care may be reduced using shift systems in that the same doctor is not available for a full 24 hour period to provide input into patient management. However, a well designed shift system, with built -in handover periods should help to aleviate some concerns of those people who are so against the introduction of shift work. The unpredicatability of some on-call rotas means that a doctor could have been asleep for 15 minutes before being woken to deal with a problem or answer a query, only to fall asleep again and have the cycle started once more. Surely a system where doctors are awake at night and allowed to go home in the morning is preferable to the current arrangements where potential for sleep at night is, at best, unpredictable, and, at worst, unavailable. The planning of annual leave or study leave may appear to be difficult when working a shift based system. However, if the shift pattern is sufficiently flexible to allow changes, and has made allowances for annual or study leave, then there will be less difficulty involved in obtaining time off for leave purposes. It is up to junior doctors working unfavourable shift patterns to negotiate changes with their employing trusts and seek changes to the working arrangements to create a system which allows maximal educational opportunity, acceptable service provision and sufficiently flexible working arrangements to make the implementation of the EWTD more appealing to medical staff rather than a change which is to be resisted at all costs. The sooner this is acknowledged, the sooner doctors can begin to work with trusts to seek mutually more acceptable working patterns. Shift systems are here to stay. It is now time to shift 24 hour resident on-call systems into medical history books. Competing interests: AR is the Junior Doctor Representative for Royal Manchester Children's Hospital and is involved in negotiation with the trust concerning changing working patterns. Opinions expressed are entriely personal. |
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Aman Chandra, Pre-registered house officer Kent and Sussex Hospital, Tunbridge Wells, Kent. TN4 8AT
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Aitkin and Paice (BMJ 2003;326:48) showed that the majority of training doctors would like to work a 56 hour week with 13 hour shifts. They nonetheless allude to the fact that reduction in hours and the consequential shift systems may be detrimental to juniors training, a concern that has been raised in the past (Kapur N et al. 1998). This is my personal concern. As a house officer approaching the end of my house jobs at two district general hospitals, I have experienced a job with old style 24-hour team based on calls and a job with a partial-shift on call that has recently needed to change to a full-shift system to comply. My preference is overwhelmingly with the former. The benefits of staying on call throughout, and following patients from presentation in hospital all the way through to final outcome is a thorough education and continuity in patient care. The converse is my experience with the shift systems. The house officer, who clerked the patient in, is unlikely to present the patient to the consultant the next morning, let alone follow them through. This loss of continuity, in my opinion, results in stunted education and, more importantly, interruption in patient care. My fear is that by sending us to bed early, my predecessors and the government, however well meaning, have in fact shot themselves and me the foot. I believe that I should be in the hospital now, learning as a protected house officer, not sent home early whilst registrars and SHOs cover. The real danger is of breeding doctors who will not be nearly as experienced as they climb the professional ladder. This will obviously affect the health service. Paice (1998) suggested that acquisition of experience had more to do with organisation and supervision rather than long hours. Salter (1995) suggest that making a post analogous to “Chief Resident” found in US residency programmes, better support systems and earlier starts to the working day may help with the need to reduce juniors’ hours. These are very valid, and whatever is implemented, my experience does not lend me to favour just a shift system. My final concern is that one day I shall be on call in hospitals when I am a grey man with more personal responsibilities, covering for juniors who, like me now, must be sent to bed. Do others feel the same? Aman Chandra MBBS BSc
References • Aikten M, Paice E. (2003). Trainees’ attitudes to shift work depend on grade and specialty. BMJ 2003;326:48 • Kapur N., House A. (1998). Working patterns and the quality of training of medical house officers: evaluating the effect of the ‘new deal’. Med Educ. 32 (4):432-8 • Paice E. (1998). Is the new deal compatible with good training? A survey of senior house officers. Hosp Med. 59 (1): 72-4 • Salter R. (1995). The US residency programme- lessons for pre- registration house officer education in the UK? Competing interests: None declared |
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