Outcomes of the European Working Time Directive
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.39541.443611.80 (Published 31 July 2008) Cite this as: BMJ 2008;337:a942All rapid responses
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The presumed aims of the Council of the European Union as listed in
the editorial(1) fail to address the initial purpose of the Working Time
Directive, which was simply to protect the health and safety of workers
(2), medical or not. Assumptions on the impact it may or may not have in
old habits within the medical profession and how it will translate into
patient care are speculative, entirely based on personal opinions which
can be diametrically opposite and totally out of the remit of the Working
Time Directive. This latter point was reinforced by the SiMAP(3) and the
Jaeger(4) rulings.
Both the European Working Time Directive and the Modernising Medical
Careers project (5) can contribute to a welcome shift in speciality
training if adequately nurtured. The underlying principles are laudable
and relevant, despite the difficulties that different professionals are
having in putting them into practice, often but not always of a covert
financial nature.
It is recognised as important that doctors become more responsible
for their own continuous education and assume a clear role as active and
reflective learners. Such a redirection in speciality training, and even
in career approach, should be supported and not compromised by management
difficulties and service provision. This will have the potential to help
young doctors become better clinicians who will not, restrained by fear,
become merely safe providers of a given service.
The Working Time Directive was, as stated in the editorial, was
produced by the Council of the European Union in 1993 and incorporated
into British law in 1998. This would have allowed the medical profession
enough time to reorganise itself in terms of training of its new members
and provision of services. The Working Time Directive itself should not be
blamed for the failure in a smoother implementation.
Although this was not its initial aim, the European Working Time Directive
should be seen as an opportunity to redirect specialty training, giving
more emphasis to purpose rather than merely procedure.
Ref:
(1) BMJ 2008;337:a942
(2) Council Directive 93/104/EC of 23 November 1993
(3) http://eur-
lex.europa.eu/smartapi/cgi/sga_doc?smartapi!celexplus!prod!CELEXnumdoc&lg=en&numdoc=61998J0303
(4) http://curia.europa.eu/jurisp/cgi-
bin/gettext.pl?lang=en&num=79969090C19020151&doc=T&ouvert=T&seance=ARRET&where=()
(5) http://www.mmc.nhs.uk/default.aspx?page=310
Competing interests:
None declared
Competing interests: No competing interests
Why is it that clinical care amongst nursing staff has not broken
down when nurses only work for 37 1/2 hours a week ? Why is it that
doctors feel this need to suffer for their art so much ? The answer to the
latter is that we have inherited habits from our predecessors who, pre-NHS
worked in "Firms", much like Chambers of barristers, who trained junior
staff by a process akin to indentured apprenticeship. An old Professor of
mine once told me how he had had to ask his Consultant's permission to
leave the hospital and cross the road to the shop during his house officer
year. He was always on duty. But it was during the Second World War. When
he told me this, it was not to tell me that this was how he had gained his
invaluable experience, but to remind me that life for junior doctors used
to be far worse. Maybe we all should look to how we would like to work in
the future and try to achieve this ideal. I say less hours, not more.
If I were training a pilot, the usual profession we compare ourselves
with when looking at risk management, I would not expect the trainee to
efficiently acquire skills when tired and resentful during the training
sessions. I would focus on the trainee actually flying the plane, not
polishing the windows or emptying the waste-paper basket.
In my experience as a junior doctor, training has always been highly
diluted with service provision, and so long hours were needed to distill
any meaningful training experience out of the hours of unnecessary tedium.
During this process, "in the good old days", disillusionment had to be
constantly fought off when for example on call, one was paid at one-third
time and the hospital management thoughtfully closed the restaurant for
those working out-of-hours and clamped your car. Trainee pilots might at
least get a smart uniform and would not be expected to be pre-occupied
with hunger pangs mid-flight. But they were never "t'apprentice lad", to
be used and abused by the Firm.
The simple fact is that we are trying to train our juniors on a
shoestring budget, and with a shoestring mentality. Nurses appear to have
rewarding careers and acquire skills without the need for inhumane hours.
I often observed that despite the nurses changing shift three times a day,
patients would often say how wonderful they were and leave them a box a
chocolates. The poor junior medical staff in the good old days of 83 hours
a week rarely got remembered. Why ? Their quality of the patient
interactions may have been high, but the quantity low.
For continuity it would be far safer for all to have juniors working
with the same team of nurses on their rota system to provide the service
component of clinical care, and to be intermittently sent away to "flight
school", a few weeks of clear training, not confused by "being on duty",
and then on return given more responsibility. Start by polishing the cars,
then be allowed to open the bonnet. You will then need to start training a
new polisher however. You will need more staff. It will be more expensive.
That is inescapable.
What is needed here is a total change of training philosophy and
expectation, not just trying to force the old system into a new shape that
may look new, but as has been pointed out, is not fit for purpose due to
the inherent flaws and weaknesses of the recycled tired old design.
Finally, I would ask all the readership to consider Oxford and
Cambridge Universities. These are both sucessful educational
establishments with a long history of teaching over hundreds of years. If
being tired assisted learning, if holding down an additional full-time job
assisted learning, if sacrificing personal development and neglecting a
social life assisted learning, why have they never attempted to ruin their
students' lives in the same manner that our profession continually
encourages us to ? I say again, "Less hours, not more".
Competing interests:
None declared
Competing interests: No competing interests
We concur with the issues raised by Cairns and colleagues (1)
regarding the implementation of the European Working Time Directive (2),
which will lead to a reduction of junior doctors working hours next year
to forty-eight per week. Of particular concern is its negative impact on
their hands-on training and on the continuity of patient care.
Even with the current fifty-six hours a week, and allowing no more
than 12 hours of shift work at a stretch, it is a major juggling act to
set a workable rota. As a result the annual leave of every junior doctor
is now tied up into virtually inflexible chunks within the rota, whether
they like it or not. Also, with these complicated rotas, it has become
much harder to make duty swaps at short notice. The way things are, every
trainee doctor would be better off warning their parents, partner or any
other loved ones who really matter, not to fall ill or even have an
accident within certain dates when it is particularly difficult to have
time off work. We would also advise the junior doctors to plan ahead their
special occasions such as a wedding or a birthday, as per their rota,
while fully accepting that some of their colleagues and friends would not
be able to attend their big day because of being on call.
Although, on average, the number of junior doctors per firm has
increased in the past few years, it is now seldom that the whole team is
available to us at any given time, as one doctor could be doing nights for
the acute take, while another might be away on annual or study leave. We
had two Foundation Year 2 trainees working in our unit for the six months
till August 2008, and they were both together in our ward for just three
days during the entire six months. This situation is causing serious
problems with continuity of care and promoting a consultant-led service by
default.
With the fixed shifts, protected times and reduced working hours, we
also dread the development of an undesirable attitude of continually
watching the clock while at work. This attitude could easily be taken a
step further by frequently ‘passing the buck’, that is leaving unfinished
clerking and other work to the next person on-call.
References:
1)Cairns H, Hendry B, Leather A, Moxham J. Outcomes of the European
Working Time Directive. BMJ 2008; 337:a942.
2)Council of the European Union. Council directive
93/104/EC.1993.http://eur-lex.europa.eu/ LexUriServ/site/
en/consleg/1993/L/01993L0104-20000801-en.pdf.
Competing interests:
None declared
Competing interests: No competing interests
A little publicised effect of shift-working and the reduction of
trainees' hours is the ignorance of the circumstances leading to a
patient's death. This often is the case when death occurs over a weekend
or holiday. A junior member of the team will be asked to complete a death
certificate having had no knowledge of the patient in life or the terminal
events. The other members of the team who could perhaps provide this
information have gone off shift and the relatives will be anxious to
receive the certificate to proceed with burial. Medical students now
receive little teaching in pathology, death certification or the role of
the Coroner. Consequently, trainees are puzzled by what to put on the
death certificate and whether to refer the case to the Coroner. In many
cases this results in unnecessary autopsies, delayed funerals or
inaccurate certification.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir
The recently published above article has given a comprehensive
overview of the European Working Time Directive (EWTD). The article
mentions that 'A court ruling by the European Court of Justice that every
hour on call- even when at home undisturbed or asleep in the hospital-is
an hour worked has added to the difficulty (SiMAP ruling).
This infers that the off site on call (on call- available away from
work place) and undisturbed (not contacted) hours are counted as hours
worked. This view is in a complete contradiction to the SiMAP (Sindicato
de Médicos de Asistencia Pública ) ruling and its interpretation by the
Department of Health (DH), United Kingdom. The DH in its interpretation of
SiMAP ruling stated 'If they (on call doctors) must merely be contactable
at all times when on call, only time linked to the actual provision of ...
services must be regarded as working time. The SiMAP ruling is a judgment
made by the European Court in October 2000 in answer to a claim by doctors
in Spain, that the time spent off site resident on call be defined as work
(Department of Health, 2005)
SiMAP ruling
3. Time spent on call by doctors in primary health care teams must be
regarded in its entirety as working time, and where appropriate as
overtime, within the meaning of Directive 93/104 if they are required to
be at the health centre. If they must merely be contactable at all times
when on call, only time linked to the actual provision of primary health
care services must be regarded as working time.
The Advocate General in a statement opines (with regard to primary
care teams of Spain) that the situation was different for doctors on call
by being contactable at all times with out having to be at centre. Though
the on call doctors were at the disposal of their employer, and
contactable leaves them in a situation where they may manage their time
with fewer constrains and pursue their own interests. Therefore in these
circumstances, only time linked to the actual provision of services has
been regarded as working time (CVRIA, 2000).
In the United Kingdom the General Practitioners who provide the
primary care services do not fall within the remit of the EWTD as they are
self-employed (RCSE,2004). For the hospital doctors who provide secondary
and tertiary care, off site on call for many specialties is more than
'merely contactable' for advice from distance. Many acute Medical
Specialties and all the Surgical Specialties off site on call, often does
involve returning to workplace with a view to providing their professional
services. This is in violation of EWTD minimum daily consecutive rest
period. Off site on call requires total commitment from the doctors and is
not possible to pursue their own interests while being on call.
The DH must revise its interpretation of SiMAP ruling as it is not
applicable with regard to the provision of on call services in the
hospital based practice in the United Kingdom. Therefore in my opinion
that every hour on call-even when at home undisturbed or asleep in the
hospital is an hour worked.
Thank you
Yours sincerely
Mr Anthony Victor Babu Bathula
Bibliography
CVRIA (2000) SiMAP Judgement of the court. [Internet]
Luxembourg. Available from
http://curia.europa.eu/jurisp/cgi-
bin/form.pl?
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urtpi&jurtfp=jurtfp&alldocrec=alldocrec&docj=docj&docor=doco
r&docop=docop&docav=docav&docsom=docsom&
docinf=docinf&alldocnorec=alldocnorec&docnoj=docnoj&docnoor=
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=allcommjo&affint=affint&affclose=affclose&numaff=&
ddatefs=&mdatefs=&ydatefs=&ddatefe=&mdatefe=&ydatefe=&nomusu
el=&domaine=&mots=SiMAP+Ruling&resmax=100&Submit=Submit
Accessed on 24th of August 2008.
Department of Health (2007) What is the European Working
Time Directive? [Internet] London. Available from
http://www.dh.gov.uk/en/Managingyourorganisation/Humanresour
cesandtraining/Modernisingworkforceplanninghome/Europeanwork
ingtimedirective/DH_077304
Accessed
on 24th of August 2008.
The Royal College of Surgeons of England (2004) European
Working Time Directive [Internet]. London. Available from
http://www.rcseng.ac.uk/fds/nacpde/eea_qualified/ewtd.html?searchterm=EWTD
Accessed on 24th of August 2008.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
The anxieties about EWTD on service delivery, training of doctors and
most importantly – patient safety, are widespread but do not justify the
retrograde proposals suggested in the editorial by Cairns et al(1).
Many Acute Trusts in the country are developing solutions that will
address all three aspects simultaneously. The Royal Colleges are working
collaboratively to find solutions and the Royal College of Surgeons of
England recently published its own forward thinking views(2).
The EWTD is presenting new and unique opportunities for doctors to
develop generic handover, leadership and team working skills. Many Trusts,
sponsored by the National Workforce Projects (NWP) and led by Wendy Reid,
the postgraduate Dean for London, have contributed to a range of solutions
for Hospital at Night and can be found on its website
www.healthcareworkforce.nhs.uk.
As a Medical Director with a significant interest in surgical
training and governance, I have led an internal EWTD project addressing
all the issues that arise from reduced hours and having a Hospital at
Night team to maximise trainee time in the day and evenings. Workforce
requirements, handover and ways of working are constantly reviewed and
improved depending on access and safety monitoring. On a nightly basis,
there are numerous educational opportunities for the stream-lined night
team of doctors and outreach nurses. Escalation protocols for seeking a
senior opinion have been established to ensure more senior doctors do not
do routine full shifts at night but are contacted appropriately. The
number of learning events at night for a trainee doctor covering only one
specialty in the past could never match what is available now.
The transition to a new way of working does not simply happen. In my
Trust there is a group of consultants and senior nurses from a spectrum of
specialties who have all contributed to a new philosophy and approach to
team working. Trainee input has been a vital component.
The Trust has developed an IT system in collaboration with NWP and
support from the EWTD working party of the Royal College of Surgeons of
England. It is about to be launched and will become available to all
Trusts. Trainee doctors have played a key role in the development. A
Hospital at Night Tutor (a consultant) oversees the generic requirements
of education and the Executive Boards and Chief Executive regularly
monitor progress.
Like Cairns et al, I come from a generation who were ‘working’ very
long hours. In my experience, the learning opportunities diluted
significantly with progression up the specialist training pathway. The
EWTD presents a unique opportunity to provide better training and quality
of life for doctors, improve safety for patients and clinical outcomes for
acute hospitals but a very different approach is required, that is from
'Ward to Board'.
1 Cairns, H. Hendry, B. Leather, A. and Moxham J. Outcomes of the
European Working Time Directive. BMJ 2008; 337: 942
2. Working Time Directive 2009: Meeting the challenge in surgery.
Royal College of Surgeons of England, June 2008
Competing interests:
None declared
Competing interests: No competing interests
We agree with the timely points made in this editorial that
summarises the fictional pros and factual cons
of the European Working Time Directive (EWTD). In the absence of net
benefits for patients or staff, one wonders if there were political
advantages of the EWTD so readily uptaken by the current British
Government but largely ignored by other European countries.
A survey of the impact of MMC and EWTD on 440 doctors in training
conducted by our group recently showed that much of the core training
necessary to confidently progress to specialty training is being
neglected. Thus leaving trainee surgeons inadequately prepared, and in
some cases misguided, for the demands of a surgical career.
To avoid permanent damage, other than to this generation of trainee
surgeons whose potential now may never
be realised, it would take courage from this Government to act. Perhaps
the accumulating evidence may be studied
by a National Institute for Health and Clinical Excellence to offer
helpful guidance in avoiding the death of British surgery.
Competing interests:
None declared
Competing interests: No competing interests
The exploration by Cairns and colleagues (1) and suggestions for
future direction with the European Working Time Directive are of high
interest and importance to all doctors, particularly those of us that have
worked and experienced the traditional on-call system as well as more
recently shifts and partial shifts.
32 hour on calls with an hour of broken sleep wasn’t in the best
interests of patients, doctors or other road users on the drive home and
there would be no justification to return to this. I agree with the
comments with regard to training opportunities in the current system but
the length of training should be increased rather than a return to old
dangerous practice. The author’s suggestion of maintenance of the current
limit of 56 hours but not a further decrease to a maximum of 48 hours
seems optimum.
However, the suggestion that not all time on-call should be counted
as work is worrying. Any time on duty for the NHS should be work, when not
actually engaged in clinical activity or even when on-call from home this
is not free time but restricted time when doctors can do a limited number
of activities in case they are required to resume “work” activity at
immediate notice. Not counting all time on duty as work will predictably
lead to much longer shifts. Working a 48 hour weekend but only actually
being paid for half of it because the rest was not “work” (but equally not
free time that the doctor could use constructively as they wished) is not
acceptable but likely to be the position adopted by NHS trusts if the
rules are changed.
(1) Hugh Cairns, Bruce Hendry, Andrew Leather, and John Moxham
Outcomes of the European Working Time Directive BMJ 2008; 337: a942
Competing interests:
None declared
Competing interests: No competing interests
As a surgeon who trained intensively in pre-Calman days (AND enjoyed
a colourful social life during whatever hours were free), its been
salutory to realise that I was head and shoulders above present day
specialists in clinical skills and confidence at the times of our
respective appointments. Its not for nothing that one repeatedly hears
colleagues exclaim "Who, under present day training regimes is going to
have the skills to look after me when I'm old?". Cairns and colleagues
are understating the case when they call for a halt to the reduction in
training hours. Furthermore, they fail to mention that it has been our
own 'trade union' who has been a principle exponent of these profoundly
damaging directives. And it really isn't sufficient 'mea culpa' for the
BMJ to give their views prominence as a leading article. Nor does the
squirming rapid response of Thornley and his BMA colleagues say anything
to justify past errors.
Cairns and colleagues maintain that "British medicine is highly
respected worldwide". By what yardstick? Up until the early 1990's medical
graduates from advanced Western countries (Australia, Germany and even the
USA) competed in their thousands to get experience in British hospitals.
Now they are hardly ever seen, and it isn't the immigration laws which are
responsible. Similarly,up until the same period, foreign patients flocked
to seek private medical treatment here. Now they hardly come. And why does
almost every Premiership footballer who needs top class knee surgery go to
Germany or the USA?
In the final analysis, this sad decline in our international medical
status comes back to the intensity and quality of the training of medical
graduates. Cairn's article should represent only the opening salvo in a
fightback to recover ground from those who have, almost unopposed, done
so much damage to our profession.
Competing interests:
None declared
Competing interests: No competing interests
EWDT editorial: in whose interest?
I note the editorial decrying reduction in JHD hours to 48 pw, but:
1. all the authors were very senior doctors; none were JHDs.
2. shift work, including a series of nights, is very common in all walks
of life, including nursing, and has been a fact for A+E JHDs for years.
3. 'On call' work is work and a powerful learning experience as senior
advice is often not literally next door.
4. if formal tuition were better, the tutors themselves better educated
and prepared tutorials better, then training would be better and need less
'on the job' experience ie longer hours.
5. Continuity is important but are the authors objections really more
about loss of control over their JHDs than it?
6. I am appalled that the authors should seek to exempt JHDs from the
EWDT. This comes but one step behind a practice common in some industries
of "sign this exemption form or you dont get the job". It is redolent of
the old attitude during my PG training of "if you dont like the hours,
you're not fit to be a doctor and theres plenty of others who will".
In summary, was the article written truely in the interests of JHDs and
patients or was it more about power?
Competing interests:
None declared
Competing interests: No competing interests