Calling time on doctors' working hours

Abstract

Leading physicians in the UK are warning that the imminent introduction of a new European directive to curb junior doctors' working hours will put patients' safety at risk. John House reports. Leaders of the UK's medical profession are calling for a Europe-wide effort to address new legislation that will come into force across the European Union (EU) in August to restrict the number of hours junior doctors are allowed to work. British doctors say the European Working Time Directive (EWTD)—aimed at protecting employees from excessive working hours—has gone too far and will have disastrous consequences for patients and doctors. An attempt by surgeons in the UK to gain exemption from the directive has failed. The profession is waiting to hear from the European Commission on whether hospitals will be able to delay implementation of the law, which, according to some doctors, is the only way to avert a catastrophe in August. However, UK doctors are not united in their views on the new hours, and there is an absence of any concerted effort at cooperation between national professional bodies in Europe. Meanwhile, the UK's National Health Service (NHS) is under pressure to ensure junior doctors are EWTD-compliant. Hospitals are implementing rotas that doctors say provide poor levels of staffing during evenings, nights, and weekends. Up until the 1990s, junior doctors in Britain routinely worked more than 100 hours a week. However, over the past two decades there has been a drive to cut doctors' hours and the profession is now protected by EU employment directives. At the moment the EWTD limits junior doctors to an average of 56 hours a week, and from Aug 1 they will be limited to 48 hours. According to the UK Department of Health, 48 hours is consistent with “patient safety, high quality patient care and a good work–life balance for doctors”. Across the EU health-care sector EWTD violations have been commonplace but the European Commission has recently prosecuted employers in Greece and Germany whose doctors worked in excess of 56 hours. Non-compliance with EWTD could be financially crippling for the NHS. The medical profession is divided over whether the 48-hour week is a good or a bad thing. Wendy Reid, consultant in obstetrics and gynaecology, and National Clinical Advisor to the Department of Health for EWTD, says, “no one wants or deserves to be treated by tired doctors who may make mistakes”. She adds: “it is not a badge of honour to work excessively long hours and ‘survive’, we have to move away from this macho, long hours culture and practise medicine with the patient at the centre of the service.” Andy Thornley, specialist registrar in cardiology, and chairman of the British Medical Association's (BMA) Junior Doctors Committee, explains that the BMA has supported EWTD to improve work–life balance and limit excessive hours. “Our research shows that two thirds of junior doctors are in favour of the implementation of the 48-hour week.” However, England's Royal College of Physicians (RCP), Royal College of Surgeons (RCS), and Royal College of Anaesthetists are warning that the 48-hour week will stretch staffing levels to breaking point, disrupt continuity of care, and substantially reduce the clinical exposure junior doctors receive. Andrew Goddard, consultant gastroenterologist and director of the RCP's Medical Workforce Unit, says that far from saving patients from the mistakes of tired doctors, the 48-hour week could be creating a patient safety “time-bomb”, as the next generation of consultants will lack the experience of their predecessors. Though they may work fewer hours, doctors are finding that they have to work more intensive shifts, with more hand-overs between shifts. To ensure that no individual exceeds an average of 48 hours a week, many NHS trusts are cutting the number of doctors on duty at any one time. Doctors say this puts unacceptable pressure on staff who are already overstretched. “Trust managers might think their rotas work on paper, but the clinicians on the ground disagree”, says Goddard. Most of the country's hospitals struggle to provide adequate staffing levels with a 56-hour week, explains Goddard. He warns that by August hundreds of hospitals will be unable to maintain a 24-hour acute admissions service. “The NHS cannot deliver the 48-hour week—the people just aren't there”, adds John Black, consultant general surgeon and president of the RCS. According to the Colleges, senior doctors in several specialties already feel the 56-hour week does not provide satisfactory continuity of care or adequate training, and the 48-hour week will only make things worse. At the end of 2008, the RCP carried out a survey of doctors in trusts where the 48-hour week was being phased in, and found that 71% of respondents said continuity of care was worse, and 52% said the training they received was worse. “It's gone too far at the expense of safety, training, and trainee lifestyle”, says Black. Reid says doctors must adapt: “Well conducted, senior lead handover is good for patient care, it is when handover is not valued and performed poorly that risk arises.” She adds, “nurses have managed handover in a compliant working week for a long time and we can learn from our professional colleagues”. The BMA, although it supports the introduction of EWTD, has recently recognised its likely problems. The BMA's solution is to increase consultant numbers so that over time, service provision will be led by senior rather than junior doctors. The BMA is working on measures to address staffing and training problems during the transition to consultant lead care. But dissenters feel betrayed by the BMA and are not convinced by consultant lead practice as a solution. Most vehement among them is Black who has been warning in the national press that the new hours will have catastrophic consequences for patient safety and waiting lists. The RCS has unsuccessfully lobbied the government to appeal to the European Commission for a group opt-out for surgeons that would allow a maximum 65-hour week. Black says 65 hours is compatible with “a normal working week with one in six on-call”, and would provide better continuity of care, more doctors on duty, and more training opportunities. A 65-hour week “could be pursued if there was political will”, says Black. But “within the present government there is no such will”. Goddard says the RCS has alienated the government. The RCP approach is to cooperate with government so that it has an opportunity to influence policy. The College is working with the government to secure from the European Commission a temporary 2-year extension on the Aug 1 deadline. The Department of Health is seeking a “limited derogation” from EWTD for an extra 4 hours per week, “that could be applied in hospital services providing 24-hour immediate care”. Goddard says hundreds of hospitals will need derogation and admits it only delays the inevitable. He explains that the RCP plans to measure the effect of EWTD over the next 2 years and present the results to the government and to the European Commission. The EWTD does allow individuals to opt out of the 48-hour week and the government says that it is committed to protecting the rights of individual doctors to opt out and work a 56-hour week. But some European politicians want to phase out this provision. Remedy UK—a doctor's pressure group—is calling on the government to oppose any removal of the opt out. However, a source close to the NHS Confederation, an industry body that represents NHS management, told The Lancet that NHS employers feel uncomfortable with the opt out because they fear litigation from doctors who might allege coercion into opting out. Goddard and Black both agree the problems posed by EWTD cannot be addressed on a national basis. The only way forward is for professional bodies in all EU member states to campaign. Goddard says doctors in other European countries are waiting to see what the UK does in response to EWTD. The UK has traditionally been a leader in the European profession and unlike other EU members the UK has a state monopoly on health care. The RCP keeps abreast of developments in the European health-care sector and liaises with the European Commission director generals. The RCS participates in the European Union of Medical Specialists, which represents national professional bodies from 35 European countries. However, the Colleges are not actively working with other European bodies on EWTD. UK doctors opposed to EWTD anticipate a bleak future. Black predicts that: “surgeons will use their limited hours to provide first, the safest possible care, secondly, the best they can do to provide training—waiting list targets and everything else will come a long way behind.” Women in medicine—a future assuredIn 2004, Professor Carol Black , who was then President of the Royal College of Physicians (RCP), asked whether the increasing number of women in medicine might lead to a loss of influence and downgraded professionalism. She called for equal numbers of male and female doctors, rather than more women, to preserve balance and professional status. A review was initiated to look at the likely impact on medicine of the increasing numbers of women in the profession. The result, Women and medicine: the future, a report prepared on behalf of the RCP, was released on June 3. Full-Text PDF