More doctors is not the answer to the EU Working Time Directive
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7380.68/b (Published 11 January 2003) Cite this as: BMJ 2003;326:68All rapid responses
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Editor
In its statement that the EU working time directive should be
implemented for doctors in training without simultaneously increasing
doctors numbers, the Department of Health is revealing a tacit acceptance
of lower standards of patient care. Its recommended alternatives to
increasing medical manpower serve only to make the hours reduction
affordable.
Over the last ten years, since the first initiative to reduce junior
doctors hours of duty, there has been a progressive reduction in the
levels of medical cover on wards and a resulting decline in the standards
of care provided, particularly for post operative patients. Consequently
problems are detected late, sometimes when corrective action is no longer
possible.
The merit of reducing further the hours of work is for debate
elsewhere, but if it is felt to be necessary it is folly to suggest that
it can be done without replacing those doctors taken from the wards with
others of equal standing. A football team playing with only ten men is not
the same effective unit as the full side. It may make do, by extra effort,
for a short while, but will surely not be able to sustain performance
throughout the season.
The statement of the chairperson of the junior doctors negotiating
committee "hopsital mergers may be inevitable in order to produce the
critical mass of doctors required to ensure patient safety" suggests
humble expectations. Surely we shpould be offering more to hospital
patients than basic safety.
Alan R Berry
Competing interests:
None declared
Competing interests: No competing interests
The working Time directive has been titled the Waking Up directive
in certain quarters and will herald a major change in the delivery of
medical care in hospital environments. There is no 'one fits all
solution' but avoiding recruitment of extra doctors, and consultants
in particular, in the early phases of implementation will make any
plan unmanageable.
"Creative redesigning" or shift work will only be a solution in some
areas where there is a requirement for staff in a specialty to be on-
site for 24 hours. In order to staff a rota over a 24 hour 7 day period
incorporating prospective cover for annual leave, continuing
professional development, CME commitments and with a
contingency for unplanned events such as illness then a minimum
of 9-10 doctors will be required for one to be available with a built
in handover period for patients undergoing treatment.
Senior doctors in many countries are already covered by the
working time directive and will thus not be in a position to directly
increase their hours to compensate reduced working hours for
junior doctors. Few consultant rotas I know have 10 physicians on
them and many smaller institutions have only 2 or 3.
If work is to be redirected to other new grades of technical staff
these will also have to be trained in and those physicians currently
employed will not be in a position to develop curricula de novo,
maintain service commitments and ensure that the new staff are
available to work when the directive is fully implemented.
Reducing working hours for junior doctors should not result in an
expansion of this grade as this will not enhance quality of care for
patients who will be even less likely than now to be treated by a
consultant in the early stages of their illness. It will also have
adverse impacts on the career progression of this group.
During recent discussions on junior doctor working hour "creative
redesigning" in Ireland it was suggested by some management
sources that any surgical specialty could cross cover the others at
night reducing the number of rotas from 7 to 1 as all these doctors
would have had some basic surgical training. Such statements
only emphasise how poorly understood the delivery of quality
specialist medical care is in some management circles.
What makes this matter so complex in some countries is the
political involvement in the geographical organisation of
healthcare. No politician wants to see the service changed in his
area particularly if this involves closing the emergency department.
Hard decsions though will be required from administrators and
health ministers in our jurisdictions and the earlier this happens
the less expensive this will be.
In Ireland initiatives have been taken by the training bodies which
will remove training accreditation from emergency departments
which do not have an 8 session consultant commitment in
Emergency Medicine. This has been portrayed as the colleges
closing the hospitals by the majority of media sources and has
generated considerable comment. Informed media sources have
suggested though that if politicians are unwilling to make the hard
decisions then the profession should do it.
To paraphrase the Proclaimers
I would work 48 hours
I would work 100 no more
Just to be the man who works 100 hours
and falls down on your floor
The directive is inevitable we should do what we can to encourage
early implementation locally improving junior doctors working and
training conditions and making the hard decisions for those
politicians unwilling to do it
Competing interests:
Past President Irish Medical
Organisation
Competing interests: No competing interests
The Department of Health ought to recognise that the European Time
Directive (ETD) has a significant impact on doctors'training. The
reduction in hours and formulation of shift work patterns will mean even
more service provision whilst working and less training in one's
specialty. The number of trainees in a hospital is fixed (and few in
numbers) and patients unattended by those away on a different shift would
still have to be reviewed.
The UK is already inefficient in training specialists. In the US and
Singapore, where medical care is now superior, specialists are trained in
half the time. Training is focussed on one's specialty. Service provision
is minimal as there are more doctors to share the overall service
provision. How many more years do we need to be competent in surgery,
cardiology, gastroenterology when we start to miss training sessions
because of shifts ?
Nothing in the world comes for free. There is a cost to good health
care. Increasing doctor numbers in all levels of seniority is one step in
the right direction, allowing us to meet the ETD and achieve training
requirements.
Competing interests:
None declared
Competing interests: No competing interests
Internationally,as in this article, it is increasingly recognised
that the twenty-first century health delivery vehicle has been driven by a
nineteenth-century staff mix.
In 1985 New Zealand introduced contracts of service for junior
doctors, based on hours worked. The conditions prescribed were similar to
those now required by the European Working Times Directive. The hours
worked by other doctors was not regulated.
A huge augmentation of junior doctor numbers has occurred through
lack of attention to the overall staff mix.
This and other consequences have been reported at:
http://www.nzma.org.nz/journal/115-1166/259
Competing interests:
None declared
Competing interests: No competing interests
Time is running out for NHS Trusts and the Department of Health to act
EDITOR:
Rhona MacDonald’s article concerning the European Union Working Time
Directive raises important issues concerning the working patterns of the
medical profession.(1) We are rapidly approaching the implementation of
the initial stages of the EU working time directive. In August 2004
doctors in training should work no more than 58 hours per week; from 2009
this must be reduced to 48 hours per week.(2)
There are two main ways to reduce the number of hours in any
particular working pattern. Either the total number of hours must be
reduced (ie some of these hours must be undertaken by non-medically
qualified staff) or the number of people contracted to work these hours
must be increased.
To completely modify a working arrangement for junior staff requires
a great deal of time and managerial skills. The working patterns for
doctors in training must be balanced against the ways in which NHS Trusts
function in order to provide an adequate service for patients.
To change a working pattern for junior staff so radically means that
organisations must urgently consider alternative ways in which they
provide their service. We need to look carefully at tasks which could be
undertaken by staff who are not medically qualified, however the answer to
reducing doctors hours should not be to simply employ more nursing staff.
Roles must be clearly defined within acceptable clinical risk
guidelines. To train staff appropriately and ensure that new working
patterns are robust and cost effective will be difficult as the time in
which to do this is slipping away.
The Department of Health needs to react swiftly to issue practical
guidance to NHS Trusts to advise them about changing working patterns for
doctors in training. In the interim, until organisational change can take
place, recruiting extra doctors may be the only way in which to ensure
compliance with the directives that come into force in August 2004.
Unless action is taken soon to ensure that trusts and the Department
of Health are prepared to meet the demands of the EU Working Time
Directive then the current working patterns for many junior staff will
become unsustainable. Time is rapidly running out for NHS Trusts to act.
1. MacDonald R. More Doctors is not the answer to the EU Working
Time Directive. BMJ 2003;326:68 (11 January)
2. http://www.doh.gov.uk/workingtime/
Competing interests:
None declared
Competing interests: No competing interests