Quarter of hospitals not ready to comply with working time directiveBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7447.1034-d (Published 29 April 2004) Cite this as: BMJ 2004;328:1034
A substantial number of hospitals will be unable to comply with the European Working Time Directive in acute medicine when it becomes law in August this year, says a survey published this week by the Royal College of Physicians.
The survey of senior physicians at acute hospitals in England and Wales found that 23% will probably or definitely not be able to comply with the forthcoming directive, which rules that junior doctors must not work more than 56 hours a week. In addition, doctors are not to work more than 13 hours in any 24 hour period and are to take an 11 hour break before and after such a shift. Compliance would require virtually all junior doctors, including all doctors up to and including the specialist registrar grade, to switch to 13 hour “full shifts.”
It is the lack of the experienced “middle grade” doctors (specialist registrars or staff grades)—the key staff involved in out of hours acute care—which is the crucial impediment to compliance, says the survey. This shortage was highlighted in the Royal College of Physicians' survey of October 2002 which called for a postponement of the directive in the interest of public safety.
The new survey, conducted between November 2003 and January 2004, shows that medical specialist registrars in almost half of hospitals in England and Wales are still working a traditional on-call rota (with usually one day a week being on-call for 24 hours and every third weekend on-call). Trusts are delaying the inevitable switch to full shifts for the crucial middle grade staff until the last moment, presumably because they have insufficient staff and they know that these rotas are unpopular, says the survey report. Most of the senior house officers and house officers are already on full shifts.
The full shift pattern almost unavoidably means working serial night shifts, either seven in a row or three or four nights in a row, twice as often. The college is concerned that such a working pattern may impede the recruitment into acute specialties in the future.
Although the number of specialist registrars has increased since the last survey two years ago, 38% of hospitals still had fewer than seven middle grade staff. The survey report says that at least eight middle grade staff are needed to implement a full shift pattern safely, and it is concerned that many hospitals may attempt to introduce full shifts with only six or seven staff, inevitably putting extra strain on the affected specialist registrars. Only 40% of hospitals achieved the optimal position of having 10 or more middle grade staff.
Dr Hugh Mather, the college's specialist registrar adviser, said: “The SiMAP and Jaeger judgments on the definition of working time—effectively that ‘sleeping is working’—are proving to be impractical and damaging. We welcome the recent statement from the government and the European Commission that they intend to overturn (in effect) these judgments during the summer. Unless this is achieved, the maintenance of safe levels of acute patient care may become very difficult.”
The SiMAP judgment was a ruling of the European Court in October 2000, in favour of a Spanish trade union, the Sindicato de Médicos de Asistencia Pública (SiMAP), which had protested that some of its members were working 31 hour shifts (BMJ 2000;321:918).
The Jaeger ruling in Germany last year said that doctors were allowed immediate compensatory rest after resident on-call duties, even if they had been able to rest while on-call (BMJ 2003;327:640).
Staffing Levels in Acute Medicine in January 2004—the Lead-Up to the EWTD can be accessed at http://www.rcplondon.ac.uk/