05 March 2009
Surgery and the European Working Time Directive
What is the EWTD?
The European Working Time Directive (EWTD) is part of EU health and safety legislation which lays down requirements in relation to working hours, arrangements for night workers, rest periods and annual leave.
The directive was brought into UK law under the Working Time Regulations in 1998 and means most workers must not work over 48 hours a week unless they opt-out voluntarily. This hours limit includes all time spent training and “on-call”.
Does this apply to doctors?
Yes - The laws have applied to consultants and non-trainee doctors since 1998 – however most hospital consultants have been able to opt-out voluntarily and work the hours necessary to care for their patients.
The NHS was given more time to comply for junior doctors. A staged approach led to an interim 58 hour week, introduced in 2004, reduced to 56 hours in 2007 and due to be reduced to 48 hours in August 2009.
What does this mean for hospitals?
The cutbacks in doctors’ hours have meant NHS Trusts have had to make drastic changes in how they staff hospitals.
In the past doctors would work a standard daytime week and participate in an on-call rota to provide cover at nights and weekends. This might mean one day and weekend in six when they would be expected to be ready if needed. The system meant there was always a range of people available with the right level of skills to deal with problems or emergency admissions out-of-hours.
But, because time spent on-call would count toward a doctor’s 48 hours a week, hospitals have had to scrap “on-call” arrangements in favour of full-shift rotas. This meets the hours’ requirement but replaces “on-call” with continuous work.
Why does it matter?
In essence, there are not enough surgeons or other hospital doctors in the UK to staff 48 hour rotas and hospitals are struggling to cope. This is causing two main problems:
Patient safety and service is being compromised:
- Reduced cover - Hospital doctors are being spread very thinly. Under the on-call system a network of doctors at all levels of experience and expertise could be called out if needed. The rota system means whole levels of cover have stripped out, often leaving only a junior doctor and the consultant. If things get busy they cannot be in two places at once.
- Multiple handovers – The shift system means a doctor never get to see a patient through their surgical treatment and to take personal responsibility for providing the appropriate care. At the end of their shift they have to hand patients to a new set of doctors. Handovers have always happened – but the shift system means they happen more frequently and this increases the risk that something important gets missed.
Medical training is stalling:
- Less time to learn – much of the 48 hours would be used providing out-of-hours care, with little time for operating lists and clinics where junior surgeons learn the job. If they can’t learn who will do the operations when the current consultants retire?
- Emergency versus elective - after battling for many years to reduce waiting times for planned operations, the NHS risks throwing all these gains away in August. Consultants would put patient safety first and fill the gaps in emergency cover. They would have less time left for elective work.
Surely less working hours means more rested surgeons and better patient safety?
No – trainee surgeons have told the college through two major surveys in December 2008 that the shift system brought in to meet 48 hour limits are significantly MORE tiring than the on-call system they replace.
Under on-call a surgeon is only called out IF they are needed otherwise they rest. Under shifts they are fully at work all the time they are in the hospital and after two or three days, they are exhausted.
Can’t surgeons just opt-out?
Technically yes, in practice no – the regulations mean that individuals can voluntarily opt-out of the working hours limit and some consultants already do so. However, a rota can only work if everyone on it is working the same hours. If individual hospital doctors determined their own working hours then the rotas would become so complicated that hospital services would become hopelessly confused.
Only a surgery-wide solution will work.
Is this a problem for all doctors?
No – this is mainly an issue for some hospital-based doctors who require lengthy practical training, like surgeons, and who cover emergencies. The 48 hour limit is perfectly acceptable for many doctors who only see patients during normal working hours.
What do Surgeons want and why?
Other services such as armed forces and police have been granted exemptions from the working restrictions, as have industries as diverse as deep sea fishing and domestic service.
Surgeons in training want to be able to provide patients with the best quality of care and be able to learn new skills. They cannot do that under the proposed arrangements for EWTD.
The trainee organisations and the Royal College of Surgeons want an ‘opt-out’ for the whole of surgery to be exempt from the restrictions of the EWTD.
We call for an opt-out for all surgeons giving them the flexibility of extending their working hours up to a maximum of 65 per week. This would give patients peace of mind that hospitals are safely staffed to provide high quality care. Trainees would have time to get a good training. Tomorrow’s doctors would be as good and experienced as today’s.