How should working times change for trainees?

Separation of education and training

The report suggested that education and training could be separated from service delivery to counteract some of the negative effects of the working time rules. “Such a solution, where education and training are protected and separated, allows the potential for the profession to set down the core educational requirements that can be managed outside the core service requirements,” it said.

“With each specialty determining their needs based on the nature and intensity of the training they require, this would allow for differential time requirements. The protected training and learning time would lie outside the requirements of the WTD so long as it did not constitute ‘working time’ under the WTD,” the report said.

Richard Thompson, president of the Royal College of Physicians, says he welcomes the taskforce’s report and supports this recommendation, but that it “must be taken into account in the current renegotiation of the [junior doctors’] contract.”

Norman Williams, president of the Royal College of Surgeons and chair of the taskforce, says the directive is “having deleterious effects on training and patient care in some specialties” and that separating training and education from ward work could be one way to address this. “This will help strike the right balance between delivering patient care and ensuring that junior doctors are able to acquire the knowledge and skills they need to become specialists of the future,” he says.

The BMA says that it would be concerned by any move to separate service delivery from education and training. Andrew Collier, co-chair of the BMA’s Junior Doctors Committee, says, “We’ve always said that is impossible because service delivery and training go hand in hand. How we plan that could be revised, but you can’t separate them out and say one is work and one isn’t work for the purpose of the directive.”

Collier points to the charter that Health Education England, the Academy of Medical Royal Colleges, and the Junior Doctors Committee signed up to as part of the Shape of Training review. “In that charter it said that training and service delivery are inextricably linked,” he says. “I think that’s certainly always been our view—that you can’t pull them apart. In the future we’d be very concerned if any moves were made to separate out education and training [from service delivery]. I don’t think that junior doctors want that and I don’t think it’s sensible for the public either.”

Aside from these concerns about separating service delivery and training, Collier says most of the recommendations in the taskforce’s report are unsurprising. “I can’t see it having a huge impact on the problem that surgeons perceive to exist,” he says. “I think it needs more creative thinking. The recommendations are quite dilute in themselves, and so they almost don’t go anywhere” (box 2).

Making better use of available time

Rather than increase the number of hours that trainees work or increase the length of training, Collier says the answer could be to improve the way trainees’ time is planned. “Our fix is for the time that [trainees] already have within the directive to be better used,” he says. “That’s about sensible training and sensible service delivery, planned within the current hours envelope. So we don’t need to make the hours envelope bigger, it’s just about making better use of the time that we have.

“There’s no evidence to support [suggestions] that doctors these days are any less well trained than they were before the directive came in. They’ve done less hours by the time they’ve reached the CCT [certificate of completion of training], but there’s no adverse outcomes in terms of their ARCP [annual review of competence progression] outcomes in the summer . . . There’s no difference in people’s training outcome currently, compared with when the directive came in.”

Ian Martin, president of the Federation of Surgical Specialty Associations, also believes it is unclear how the taskforce’s proposals could be implemented. He says that, although the report discussed the impact of the current junior doctor contract on handover and continuity of care, it was disappointing that, “greater emphasis has not been placed upon the effect [of European working time regulations and the current junior doctor contract] on continuity and handover of patient care, both of which impact upon patient safety.”

Dean Royles, chief executive of NHS Employers, supports the report’s call for the junior doctor contract to be amended to address the issues of trainees’ working hours. He says that NHS Employers believes that “a fresh contract for junior doctors will help deliver better training, better care, and a better relationship with employers for this valuable group of staff.”

He adds, “The report also certainly provides further compelling weight to the need for consultants to change the way they work. Agreement on changes to national terms and conditions are needed to create more support for junior doctors at all hours, to provide better patient care at the weekends and greater safety during handovers between shifts.”

The taskforce report will not be the last work on the impact that restrictions on working hours are having on doctors in training. According to Kate Ling, senior European policy manager at the NHS Confederation’s European office, the European Commission plans to conduct a study on the impact of the directive on the health sector. “Our office will contribute to and influence this on behalf of the NHS,” she says. “It will then be for the commission to decide whether and when to bring forward a new proposal suggesting changes to the law on working time, but this won’t happen before 2015. So it will be a long process but one that we intend to influence positively.”