Intended for healthcare professionals


Why can’t medical training be delivered in a 48 hour week?

BMJ 2014; 349 doi: (Published 06 October 2014) Cite this as: BMJ 2014;349:g5947
  1. Abi Rimmer
  1. 1BMJ Careers


Responses from NHS bodies to a review of the working time directive have shown stark differences of opinion on how best to deal with the challenges of fully training doctors within a 48 hour week. Abi Rimmer reports

The European Working Time Directive has long been a point of contention in the medical profession. When the limits required under the directive were fully incorporated into the NHS in 2009, many welcomed the end of the exhausting 100 hour weeks that junior doctors used to work. Others believed that limiting doctors to working no more than 48 hours a week over a six month period would prevent trainees from gaining sufficient experience.

In September, a number of NHS organisations responded to a government consultation on the impact of the directive’s implementation in the United Kingdom. The government is gathering views on the directive so that it can submit a single response to a European Commission review of the directive. Rather than providing a single voice, the responses submitted to the government show diverging views across the healthcare workforce on the impact of the directive and how the problems caused by its implementation might best be resolved.

The Association of Anaesthetists of Great Britain and Ireland (AAGBI) raised concerns in its response about how recent discussions on the directive have been heavily weighted towards surgery. It argued that medical training could be delivered within the 48 hour limit of the working time directive and that trainees shouldn’t be forced to work overtime to train.

“It is not acceptable for someone who is covering the next nightshift to work during the day, albeit voluntarily, as this may put patients and the doctor at risk due to fatigue,” the AAGBI said. “We strongly believe that we should steer away from a path that may return us to older educational models in which training was achieved through a process of diffusion during unnecessarily lengthy hours spent at work.”

The AAGBI said it was concerned about the government’s decision to encourage individual doctors to opt out of the working time rules. “Whilst this may have merit in a small cohort of trainees for a limited period of time—for instance, to gain specific competencies in an intensive period of training—we feel that this should remain an individual trainee’s decision, made without undue external pressure,” it said. The AAGBI called instead for methods of working to be adapted so that they operate within the directive and for more up to date training methods to be adopted.

In contrast to the Royal College of Surgeons and the Royal College of Physicians, the AAGBI said that working hours should not be extended, and it argued against trainees being encouraged to opt out from the working time directive.

In its response to the consultation, the Royal College of Surgeons said that “more thought should be given to how practitioners could exercise their right to opt out.”1 But it warned that “relying on individual doctors to opt out of [the] working time rule is not sufficient to tackle the problems the directive is causing in the NHS.” It also said that “the possibility of creating protected education and training time for junior doctors should be explored.”

The Royal College of Physicians also said that the widespread use of the individual opt-out should be encouraged, and added that this could be done through “collective agreements.”

The Royal College of Radiologists made recommendations for “informal arrangements in some trusts where trainees are welcome to stay and learn even if the working time directive deems them not able to work.”

The Royal College of Physicians of Edinburgh recommended that rota designs should be improved, “to foster better training and work/life balance for doctors while maintaining excellent standards of patient care and ensuring that physically medicine remains an attractive career option.” The college also supported the Royal College of Surgeons’ recommendation for the creation of protected education and training time for junior doctors. “We expect to see options for identifying training time that is not included within working time to increase flexibility without requiring an opt out,” it said.


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.


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