Running out of time? Perhaps not
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1815 (Published 06 May 2009) Cite this as: BMJ 2009;338:b1815
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EWTD is one of the biggest issues affecting the modern NHS. There has
been a huge amount of discussion in Britain regarding the implementation
of the working hours. The government has funded the process partly, the
trusts have been forced to employ more staff, the rotas have to be jigged
in a way to make them look compliant, trainees are encouraged to 'opt-out'
and serious training and patient care issues have surfaced. The worst
impact in training has been with surgical specialties where it is
important to spend actual time learning the skills hands-on.
The author visited Belgium on a Bariatric Surgical Fellowship and in
the weeks spent there, the one thing which stood out most was the lack of
EWTD mania. A typical surgical working week in a large government hospital
included 3 full-day operating lists and 2 full days of other clinical
activities, along with the usual milieu of emergency work. A working day
started around 7:00 AM. The operating lists started with incision on
patient at 8:00 AM and the lists finished around 7:00 PM, on a good day.
Like the old British system there were two parallel lists running with the
consultant and his team working in tandem. In between cases the turn-over
was extremely rapid with hardly any time for what would be construed a
'proper' break in UK, for any of the staff involved.
My inquiries about EWTD and the arrangements in place to counter the
impact was met with a great deal of amusement. There were junior doctors
from other EU countries who seemed to have a similar reaction. It was
obvious that all were aware of the EWTD but implementing it did not appear
to be of paramount importance. The surgical staff dismissed the idea of
EWTD as not being compatible with surgical training and surgical work
ethos. Nobody really appeared hard done by not enjoying lesser working
hours. There also appeared to be an added financial incentive to work
longer and harder.
In Britain we blame ourselves in being slow to implement the
directive. Is it really being implemented in other countries at the cost
of compromising future patient care? The fact of the matter is that
surgical training in the modern NHS, in its current form and EWTD are
incompatible and no amount of protected time and simulation exercises can
replace the real thing. One or the other needs to give to have trained
surgeons for the future.
Competing interests:
None declared
Competing interests: No competing interests
EWTD: Abusing doctors, failing patients
The Royal College of Surgeons published its survey of 900 surgeons
two months after the introduction of the European Working Time Directive
(EWTD) 1. It showed that:
• 64 percent of respondents thought that quality of care had worsened
• Over half of consultants believe that compliance is achieved at the
expense of patient safety
• A third say their hospital handover arrangements are inadequate
• 62 percent of surgeons are not working a truly compliant 48 hour week
I understand the reasons for introducing EWTD. Doctors should not
work ridiculous hours. A good period of rest is needed to ensure optimal
delivery of patient care, at least in theory.
Currently, hospitals are doing all they can to ensure doctors do not
work beyond 48 hours a week. Banding for some posts have been scaled down
because on paper, doctors are not working beyond their contracted hours.
At my hospital, rota coordinators are aware some doctors are working
beyond 48 hours per week but they are not completely open about it. As
long as the rota is compliant, there should not be any problems.
I have discovered a worrying trend where doctors are staying on after
hours unpaid just to ensure there patients are properly followed through.
Most of the time, these hours are off the record books.
It is almost seen as “taboo” for doctors to talk about money. Honesty
and fairness should be at the core of any responsible organization.
Hospitals need to be open about the hours doctors are working and pay them
accordingly. EWTD is essentially legalizing the abuse of doctors.
Restricting working hours compromise patient care. EWTD compatible
rotas have led to more cross cover and shift changeovers. Handovers have
become inadequate. Continuity of care is lost and this puts critical
patients at greater risk of death.
There is already a national shortage of doctors. Restricting hours has
definitely made things worse. Its common sense, reducing the hours of
doctors who are already in short supply will negatively impact patient
care.
A more flexible approach is needed. Rotas should not be so
restrictive that trainees only get brief glimpses of the clinical course
of a disease. Regulations should accommodate trainees learning from
challenging and unusual cases. Such cases provide vital educational
lessons, which cannot be scheduled. Rotas should be re-structured to
accommodate these variable factors.
Our role as doctors is to deliver excellent patient care using the
resources available to us. The Government really needs to re-consider
EWTD. Doctor’ hours should not be restricted in such a way that it fails
the very people it is trying to protect.
References
1. Royal College of Surgeons England. Patients are being harmed by
working time limits, 11 October 2009. at
www.rcseng.ac.uk/news/patients-are-being-harmed-by-working-time-limits-
finds-new-study. (Accessed 27 November 2009)
Competing interests:
None declared
Competing interests: No competing interests