Problems in medical training won’t be solved by working time opt-outsBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5431 (Published 11 September 2014) Cite this as: BMJ 2014;349:g5431
- Sarah Liptrot, specialist trainee year 7, general surgery and coloproctology
The government believes that the difficulties that working time limits have caused for medical training could be solved through opting out of the restrictions. Sarah Liptrot argues that, rather than solving problems, this would make it harder to introduce real changes needed to medical training
For many junior doctors, the European Working Time Directive (EWTD) has become a source of anxiety and frustration.
The EWTD was fully implemented throughout the NHS on 1 August 2009. Of major relevance to the NHS were rules requiring rest of at least 11 hours in any 24 hours and a right to work no more than 48 hours a week averaged over six months.
The impact on working patterns has been profound. A cohort of junior doctors has been protected from the excessive working hours common among house officers in the mid 1990s. However, they have also been exposed to the complex and antisocial rotas required to maintain EWTD compliance. The effect of the reduction in hours is perhaps most keenly felt in craft specialties, such as surgery, where it is estimated that 3000 fewer training hours are available to current trainees than to previous trainees.1
There is now an urgent need to consider how adequate time can be provided within specialist training for the acquisition of essential competencies. Contract renegotiation for both junior doctors and consultants is ongoing, and on 22 July 2014 the Department of Health published its response to the Independent Working Time Regulations Taskforce report on the impact and implementation of the EWTD on the NHS.2
Many of the taskforce’s recommendations, including the emphasis on formal contractual arrangements for training, have been well received and are in many ways similar to those of John Temple’s 2010 review of impact of the working time directive on the quality of training.3 Temple highlighted the negative effect of full shift rotas on continuity of care and opportunities for apprenticeship learning, but he also emphasised that good rota design and motivated trainers could mitigate these risks.
More contentious is the independent taskforce’s decision to highlight an individual doctor’s right to opt out of working time regulations, a suggestion publicly opposed by the Royal College of Surgeons of Edinburgh.4 The taskforce draws attention to the fact that, under article 5 of the EWTD, doctors can opt out of working time regulations by signing a waiver agreement with their employing hospital trust.
In response to the taskforce report, the Department of Health seized the individual EWTD opt-out as a potential solution to training pressures. In fact, the department went further and promoted a model where the working week of service commitments is dissociated from time for training, in terms of both job planning and, possibly, remuneration.
The health secretary, Jeremy Hunt, emphasised this point in his response to the taskforce report. He said, “It is clear that the directive does have a negative impact on the training of doctors in some specialties. We will now look at how training and working time could be separately identified so we can give doctors the flexibility they need.”5
In considering the impact of the working time restrictions on medical training, it is important to look at two issues separately. One is the restrictions imposed by the rules of the EWTD itself. The other is the challenge that the EWTD’s implementation into UK law and working practices has posed to NHS employers. These employers have to work within the confines of existing junior doctor numbers and increasing service demands.
The main source of the problems that working time restrictions have created for medical training may not result from the EWTD itself. They may arise from the failure to develop a system of implementation free from the fragmentary influence of hybrid shift patterns. Instead, modern shift patterns have been driven by employers’ obligation to comply with the UK Working Time Regulations, which implements the EWTD into UK law.
These modern shift patterns have largely been responsible for the loss of any consistent consultant firm structure. At its best, the consultant firm was an exemplar of longitudinal assessment and mentorship, not to mention junior staff camaraderie and continuous patient care.
The complex rotas used to achieve EWTD compliance often result in rota gaps in the evenings and at weekends, and these are filled by doctors who consequently miss out on daytime training opportunities. In addition, the method of averaging weekly hours worked over six months promotes long shifts and irregular working patterns, thus further reducing contact with consultant trainers. Attempting to regain this lost experience through a culture of coming in during rest periods imperils the principal aim of the EWTD of protecting the public from tired doctors.
The reality is that individual opt-out from EWTD restrictions without structural change in specialty training simply risks creating a system focused more on service provision than training. Furthermore, the assertion that the intimate relation between acquisition of skills and clinical practice can be artificially fractured suggests a profound misunderstanding of the nature and practice of medicine. It is unlikely that the taskforce intended this interpretation when stating that “separate regulatory agreements” for service and education would be desirable.
Advocating opt-out from the EWTD at the individual level may in fact inhibit the redesign of training and the development of new methods of service implementation intended to improve continuity of care.
Individual opt-out from the EWTD combined with dissociation of service and training time raises the spectre of trusts encouraging the creation of a homogenous opted out trainee workforce for service while ceding training responsibility entirely to the medical royal colleges. It may be that the opposite approach is what is required: an overhaul of services that allows trainees to attend teaching lists and clinics and a recognition that training is inextricably linked to service.
One possible way of delivering sufficient training within work time restrictions may be to organise training more closely along modular subspecialty lines, with trainees having greater mobility and access to training consultants. This has been proposed by the Royal College of Surgeons of Edinburgh, among others.
One advantage of such modular training would be the creation of an improved training structure in an era where competency based assessment requires equitable access to training opportunities. Such modular training has a chance of success as it chimes with the prevailing desire for a consultant led NHS and centralisation of some specialist services.4 NHS England chief executive Simon Stevens has described one possible future where “some smaller NHS hospitals . . . [adopt] a different medical staffing model, more akin to that of some of the European hospitals.”6
Two distinct hospital groups could develop: a group of larger hospitals engaged in specialty training and a group of smaller hospitals that have primarily consultant led care and employ a smaller cohort of core medical and surgical trainees. The system would require the development and delivery of novel training models.
To implement such models, changes would have to be made to the job planning for trainers and recognition would need to be given, within clinical excellence award schemes, to training roles. In addition, institutions providing training would need to have their outcomes monitored as part of a quality assessment process.
Existing techniques, such as simulation, and the use of simple approaches, such as the modular delivery of subspecialty experience across wider deanery based geographical areas, have been effective in some specialties and are supported by research suggesting efficacy.7 There is also likely to be further development of simulation in undergraduate and postgraduate medicine.8 In addition, increased adoption of advanced nurse practitioner and multidisciplinary roles may facilitate the design of training centred rotas, with a key aim being the adoption of a model of apprenticeship with linkage to accredited consultant trainers for an extended period in a consultant firm.
Working patterns in UK hospital medicine have undergone seismic change over the past decades, but methods of training and models of service delivery have changed little. Without change to training provision, individual opt-out from the EWTD in the hope of accruing training through good fortune or clinical osmosis is unlikely to be beneficial. However, rather than abandoning the protection afforded by the directive, what is required is the restoration of an apprentice model of training and change in the relationship of trainees with hospital trusts.
The EWTD is here to stay and individual opt-out will do nothing to assist the wider aims of coordinated and equitable training. Rapid solutions are required, and these need to be devised within the existing regulatory frameworks of the EWTD.
Competing interests: I have read and understood BMJ policy on conflicts of interest and have no relevant interests to declare.