Working time regulations for trainee doctorsBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4488 (Published 05 November 2009) Cite this as: BMJ 2009;339:b4488
All rapid responses
Professor Roy Pounder is not perhaps quite accurate in stating that
[none of the workforce] not even consultants now work continuously. When
first appointed as full time NHS consultant neurologist in 1981 I worked
a 1 in 2 on call rota, sharing the services of two neurology SHOs with my
consultant colleague. Although additional consultants appeared from 1995
and registrars from 1998, in practice I found it easier to remain on call
for my own patients on a continuous basis with occasional exceptions, at
the same time taking part in the routine on call rota for colleagues'
patients. From February 1998 until partial retirement at the end of April
2009 I spent an average 80 hours per week working at, or travelling
between three main hospital centres. I now carry out fewer clinics but
continue to be on call for my own patients.
It has always seemed easier to get to know individual patients in as
much detail as possible when seeing them for the first time, following
them personally thereafter as necessary, thus enabling small changes in
their condition to be recognised promptly whether as a result of their
illness or treatment, rather than to expend the same time and energy
becoming familiar with more patients in less detail with much less chance
of appreciating any change in their condition.
Carrying out more clinics per week than average and providing longer
clinic slots per patient than average has been a matter of personal choice
attempting to follow the example of predecessors who had learned most from
their clinical experience. Spending more time on the ward has provided
similar rewarding experience and allowed the majority of problems to be
dealt with more quickly, reducing the need to return at night.
Physicians need considerable time to follow the course of each
patient's illness, reflect on difficult diagnoses and management and
discuss their conclusions with colleagues, acquire cognitive, visual and
manual skills and techniques and sufficient experience to recognise rarer
presentations of common disorders and drug side effects and supplement
knowledge to recognise rare disorders not only within a narrow
subspecialty, to become able to provide safe and effective treatment and
to recognise the current limitations of this.
Accepting a need to be available to continue care of their patients
when necessary [i.e. for at least somewhat longer than an average 56 hours
per week] would hasten the above process, strengthen the bond between
patient [reassured that they are looked after for most of the time by
someone already familiar with their details and willing to spend more time
at work, "putting the patient first"] and doctor who may gain greater job
satisfaction. A small increase in the number of staff on call, working a
little longer, would reduce work intensity, allow more time per patient,
with less time spent in hand-over and cross-cover, with potential to
improve efficiency and safety, increase capacity to meet average and peak
demands without delay and potentially reduce staffing costs to allow a
greater proportion of the budget to be spent on diagnosis and treatment.
Competing interests: No competing interests
Response from Professor Wendy Reid - National Clinical Advisor for the European Working Time Directive
The European Working Time Directive has acted as a catalyst for
change. The reduction of trainee doctor’s hours to 48-hours is the final
increment for all NHS staff. The improvement in work-life balance for
staff must be achieved by changes in the organisation of care that
protects patient safety and training. The Working Time Regulations (WTR)
are Health & Safety legislation and there are both flexibilities and
constraints within the 48 hour week as the reference period for measuring
compliance is over a 6 month period.
Over the past year the medical profession, through the Academy of
Medical Royal Colleges (AoMRC) and individual College representatives
alongside the BMA and trainees from both the BMA and the AoMRC, has worked
with Strategic Health Authorities (SHAs), NHS Employers and the English
deans to achieve safe, sustainable compliance. Some organisations were
able to apply for derogation from the WTR for up to two years until 2011
allowing doctors to work 52 hours per week averaged over six months. The
right of an individual to opt-out has been protected meaning if they
choose to opt out in the case of trainee doctors, it allows a 56-hour week
maximum under the New Deal contract requirements.
The New Deal monitoring showed that since September 2008 two thirds
of doctors in training have been working a 48-hour week and all trusts
have known about this final reduction in hours for the past decade. The
challenges of the past year have not been specific to one specialty or
only to one type of organisation; they have been cross specialty and type
of unit and, in some instances, included hospitals where little or no
forward planning or testing of proposed solutions had occurred prior to
August 1st. There have been two opportunities for trusts to derogate rotas
and 4% of rotas have an agreed derogation. The joint work by the Royal
Colleges and the SHAs continues both in the support to trusts and in the
scrutiny of the derogated rotas.
In the discussions with the AoMRC and others the importance of the
quality of training within the WTR has been recognised by the Secretary of
State for Health who commissioned Medical Education England (MEE) to
review the impact of the 48 hour week on training in a reduced hours
environment. MEE is about to begin this review independently chaired by
Professor Sir John Temple.
There is a range of opinion about the effect on training of the WTR.
The last PMETB survey shows ‘increased access to training’ in WTR
compliant trusts. There are anecdotal reports of increased log book
activity where a mixture of shifts and on-call from home rotas are
employed for surgical trainees and increased ‘trainee satisfaction’ seen
in individual trust’s PMETB surveys. However there are other reports of
trainees missing opportunities such as operating lists because of the pull
to out of hours cover for emergencies and lack of engagement with
consultants because of shift patterns. It seems clear that the WTR are not
the only challenge to training, particularly perhaps in the surgical or
craft specialties, and that a variety of different solutions will be
It is reasonable to ask why some units have addressed the challenges
successfully and others are struggling. I have seen both by visiting units
around England and at the National EWTD Reference group. Those that simply
approach the WTR by altering how trainee doctors work and by attempting to
recruit extra doctors into ‘trust doctor’ roles are not making sustainable
changes. Hospitals need to take a whole systems approach focussing first
and foremost on patient safety, for example timetabling handover and
ensuring consultant leadership at handover times and/or developing the
Hospital at Night model to a 24/7 approach. Changing how care is
delivered and who is ‘in the front line’ has been addressed by a number of
specialties some years ago which has seen the consultant delivered service
becoming a reality in Obstetrics and Paediatrics in many units.
There are models of care where mortality rates, length of stay,
access to specialty training and trainee satisfaction are all improved.
Not every solution is suitable for every specialty or unit but good
clinical leadership is about bringing these models into our own
organisations, where appropriate, and challenging those who believe there
is no solution except more juniors.
There are real challenges in postgraduate medical training but there
are more doctors in training and more consultants in the NHS than at
anytime and we have a responsibility to train and use these resources
effectively within the legal working time restrictions. This will allow us
to deliver safe, high quality care to our patients and improve the work
life balance of junior doctors.
I am the National Clinical Advisor for the European Working Time Directive.
Competing interests: No competing interests
Dr Pounder is exactly right when he says that patients do not want an
surgeon operating on them. And nor should we be willing to allow this to
happen. It is unconscionable to continue to insist that junior doctors
hours in an evolved epoch like today's, where work-home balance and
health and wellbeing are rightly considered important. "Because we did it"
doesn't mean they should.
It has been said, with a degree of misunderstanding, that Physician
America do not have a career path. To a certain extent that is true - and
what makes them so valuable in a teaching hospital setting. They are a
constant, reliable presence, not training for advancement but doing what
are trained to do, at approximately the junior doctor level, and allowing
student doctors and
others to take the time needed for their learning. PAs are mature
with roots in their communities, who have excellent patient approval
They offer continuity in a flexible training situation, and employing them
hospitals would be one possible solution to the current problems with
Four universities are currently training Physician Assistants in the UK,
UK Association of Physician Assistants (UKAPA) has information on training
in this country.
Competing interests: No competing interests