Lithuania's labour limits

Abstract

Lithuania's doctors are up in arms about government proposals to introduce strict limits on working time. The new legislation is billed as a safeguard for patients, but doctors assert that Lithuania's poor pay will force physicians to look for work in other countries. Yuri Svirko reports.Ausra Vozykaite is worried about her parents' lack of sleep. But she cannot turn to a doctor for help because both her parents are doctors and it is the relentless strain of their working schedules that mean they get no sleep.“Almost every night my mother or father has to get out of bed because they are called in to work at their hospitals. Like some of their patients they have serious problems with their health. They don't get enough sleep”, she says.Her parents' situation typifies that of many poorly paid doctors in Lithuania who work double shifts to make ends meet and to cover staff shortages in other departments. Health authorities in the country freely admit that they are short of qualified physicians as more and more have travelled west for better pay packets since the country joined the EU in May, 2004.Present countrywide legislation sets a maximum working week in all industries of 40 hours plus an extra 20 hours of overtime. But these limits look set to change as the government plans to introduce new legislation on working hours to harmonise with EU regulations (see panel) and ban people in several professions, including the medical profession, from working more than one shift in a row.PanelMain aspects of the EU working-time directiveThe EU working-time directive 93/104/EC sets out provisions for maximum working hours, rest periods, holidays, and breaks to protect workers within the European Union from adverse health effects and possible safety risks. The initial directive excluded some workers, among these were doctors in training, but later amendments have extended the directive's scope. Specific provisions include:•A maximum working week of 48 hours averaged over a reference period•A minimum daily rest period of 11 consecutive hours•A minimum rest period of 1 day per week•A statutory right to annual paid leave of 4 weeks•Night working must not exceed 8 hours a night on averageSpecific points for doctors•Working time is defined by the directive as “any period during which the worker is working, at the employer's disposal and carrying out his activities or duties in accordance with the national laws and/or practice”.•In 2000 and 2003, two European Court of Justice rulings (Jaeger and SIMAP) clarified that time spent on call qualifies as “working time” and is thus regulated by the directive.•The British Medical Association is currently arguing for new third definition of working time to exclude time spent on call when doctors are non-resident.•Doctors in training were excluded from the 1993 version of the directive, but were included in a 2000 amendment. The working time restrictions have applied to doctors in training since Aug 1, 2004.•It is possible to opt out of the working-time restrictions if employees agree to work more than 48 hours and if accurate records are kept. The UK is the only country in which this opt out is used.•The European Commission is currently reviewing the individual opt out. It is also looking at the definition of “working time” because of the massive implications for doctors of the two court rulings.Under the proposed legislation, doctors would only be able to work 24 hours a week with the option of 12 hours of overtime. Many doctors currently work more than one shift in a row and working 24 hours straight is not uncommon.Initiators of the move believe that this will help to prevent overwork that might influence working quality. Officials say that if doctors work more than 60 hours per week they risk serious fatigue and could endanger patients.A tripartite council comprised of employers, trade unions, and government representatives is set to decide on proposing an amendment to the current labour code.Doctors say the new legislation will be impossible to follow and Liutauras Labanauskas, president of the Lithuanian doctors association, warns a decision to cut doctors' working hours could see the number of medical staff working in towns drop. “After all, no one wants to do a job for less money”, he told local media. Labanauskas has proposed a 36 hour working week with an option of 12 hours' overtime.Ritis Lyveikis is a toxicologist at the Emergency Hospital in the Lithuanian capital Vilnius. He says that his last working week consisted of three shifts—one 24 hours and two 12 hour shifts. He is sceptical of the proposed amendment and casts doubt on its backers' claims that doctors' work could suffer if they do longer hours.“If you work in portions of 12 hours with a rest in between, you won't burn out. 60 hours means 12 hours daily from Monday to Friday with a work-free 2-day weekend. It's normal”, he says.And he warns that if the government does impose the new limits doctors will either get round it or simply follow colleagues to western Europe where they will be better paid even if they do work less hours.“If the government limits the number of working hours, it should raise the wages of doctors. But wages are still low. Doctors are leaving Lithuania and will be leaving in even greater numbers if this working hours limitation becomes a reality.“I work the time that I need. Doctors can change shifts with colleagues and can work in different places. No one counts my working hours for instance”, he says.The proposed amendment has already provoked discussion among the general public who fear it could lead to doctors heading off to western European EU countries for work, leaving a lack of quality doctors in a health sector they say already suffers from a shortage of good physicians.Jonas Sakalauskas, 53, who lives in Vilnius is at the Emergency Hospital visiting a relative. He said that while the hospital is reasonably well-equipped and has good doctors at the moment, many of the best physicians are leaving. “Since Lithuania joined the European Union last year, many fields of medicine now lack doctors who went westwards”, he says.He explains that he had a surgeon friend who left Lithuania to work in Norway on a long-term contract because of the poor working conditions in Lithuanian hospitals.In towns outside the capital the situation is worse. Paulina Rediska, 25, lives in Visaginas, a town in eastern Lithuania in the shadow of a nuclear plant soon to be closed under EU requirements.She says: “It's a terrible thing having to go to our hospital. You come in with a splinter, yet you checkout after undergoing cranial trepanation. I have come across real horror stories from there from my friends and relatives.”“For instance I know of a girl who was prescribed tablets which were categorically forbidden for her—she ended up having to be treated in hospital for weeks; my 7-year-old brother fell and knocked himself out at school playing in the playground during break and the doctors just gave him some stitches for his cut and then told him to walk home on his own in the middle of winter. They didn't even check him for concussion. Then later they misdiagnosed a broken finger he also had.”Low wages seem to compound the seemingly grim situation in many hospitals and doctors desperate to earn more than the €350 (US$455) average monthly wage for a physician in the country ask patients for extra payments to ensure good service.As in many other former communist bloc countries, polls suggest bribery is rife. According to a recent poll of Vilnius residents, 63% of respondents said they had been asked to give bribes at the capital's Maternity Hospital while 92% said that bribes had helped them to solve problems at hospitals.Government representatives declined to comment on the amendments when contacted by The Lancet, but an official at the Lithuanian Health Ministry, Vytautas Radavicius, told local media: “This is currently being dealt with by the Ministry of Labour and Social Care and our ministry has yet to formulate a final response to it.”Until then working hours and hospital conditions for doctors and their patients will stay as they are.“People say local doctors are bad and all the good ones have already left for Ireland, the UK, or Sweden. But what if something bad happens to you? Who will give you urgent treatment?” says Ausra Vozykaite. Lithuania's doctors are up in arms about government proposals to introduce strict limits on working time. The new legislation is billed as a safeguard for patients, but doctors assert that Lithuania's poor pay will force physicians to look for work in other countries. Yuri Svirko reports. Ausra Vozykaite is worried about her parents' lack of sleep. But she cannot turn to a doctor for help because both her parents are doctors and it is the relentless strain of their working schedules that mean they get no sleep. “Almost every night my mother or father has to get out of bed because they are called in to work at their hospitals. Like some of their patients they have serious problems with their health. They don't get enough sleep”, she says. Her parents' situation typifies that of many poorly paid doctors in Lithuania who work double shifts to make ends meet and to cover staff shortages in other departments. Health authorities in the country freely admit that they are short of qualified physicians as more and more have travelled west for better pay packets since the country joined the EU in May, 2004. Present countrywide legislation sets a maximum working week in all industries of 40 hours plus an extra 20 hours of overtime. But these limits look set to change as the government plans to introduce new legislation on working hours to harmonise with EU regulations (see panel) and ban people in several professions, including the medical profession, from working more than one shift in a row. Main aspects of the EU working-time directiveThe EU working-time directive 93/104/EC sets out provisions for maximum working hours, rest periods, holidays, and breaks to protect workers within the European Union from adverse health effects and possible safety risks. The initial directive excluded some workers, among these were doctors in training, but later amendments have extended the directive's scope. Specific provisions include:•A maximum working week of 48 hours averaged over a reference period•A minimum daily rest period of 11 consecutive hours•A minimum rest period of 1 day per week•A statutory right to annual paid leave of 4 weeks•Night working must not exceed 8 hours a night on averageSpecific points for doctors•Working time is defined by the directive as “any period during which the worker is working, at the employer's disposal and carrying out his activities or duties in accordance with the national laws and/or practice”.•In 2000 and 2003, two European Court of Justice rulings (Jaeger and SIMAP) clarified that time spent on call qualifies as “working time” and is thus regulated by the directive.•The British Medical Association is currently arguing for new third definition of working time to exclude time spent on call when doctors are non-resident.•Doctors in training were excluded from the 1993 version of the directive, but were included in a 2000 amendment. The working time restrictions have applied to doctors in training since Aug 1, 2004.•It is possible to opt out of the working-time restrictions if employees agree to work more than 48 hours and if accurate records are kept. The UK is the only country in which this opt out is used.•The European Commission is currently reviewing the individual opt out. It is also looking at the definition of “working time” because of the massive implications for doctors of the two court rulings. Main aspects of the EU working-time directive The EU working-time directive 93/104/EC sets out provisions for maximum working hours, rest periods, holidays, and breaks to protect workers within the European Union from adverse health effects and possible safety risks. The initial directive excluded some workers, among these were doctors in training, but later amendments have extended the directive's scope. Specific provisions include:•A maximum working week of 48 hours averaged over a reference period•A minimum daily rest period of 11 consecutive hours•A minimum rest period of 1 day per week•A statutory right to annual paid leave of 4 weeks•Night working must not exceed 8 hours a night on average Specific points for doctors •Working time is defined by the directive as “any period during which the worker is working, at the employer's disposal and carrying out his activities or duties in accordance with the national laws and/or practice”.•In 2000 and 2003, two European Court of Justice rulings (Jaeger and SIMAP) clarified that time spent on call qualifies as “working time” and is thus regulated by the directive.•The British Medical Association is currently arguing for new third definition of working time to exclude time spent on call when doctors are non-resident.•Doctors in training were excluded from the 1993 version of the directive, but were included in a 2000 amendment. The working time restrictions have applied to doctors in training since Aug 1, 2004.•It is possible to opt out of the working-time restrictions if employees agree to work more than 48 hours and if accurate records are kept. The UK is the only country in which this opt out is used.•The European Commission is currently reviewing the individual opt out. It is also looking at the definition of “working time” because of the massive implications for doctors of the two court rulings. Under the proposed legislation, doctors would only be able to work 24 hours a week with the option of 12 hours of overtime. Many doctors currently work more than one shift in a row and working 24 hours straight is not uncommon. Initiators of the move believe that this will help to prevent overwork that might influence working quality. Officials say that if doctors work more than 60 hours per week they risk serious fatigue and could endanger patients. A tripartite council comprised of employers, trade unions, and government representatives is set to decide on proposing an amendment to the current labour code. Doctors say the new legislation will be impossible to follow and Liutauras Labanauskas, president of the Lithuanian doctors association, warns a decision to cut doctors' working hours could see the number of medical staff working in towns drop. “After all, no one wants to do a job for less money”, he told local media. Labanauskas has proposed a 36 hour working week with an option of 12 hours' overtime. Ritis Lyveikis is a toxicologist at the Emergency Hospital in the Lithuanian capital Vilnius. He says that his last working week consisted of three shifts—one 24 hours and two 12 hour shifts. He is sceptical of the proposed amendment and casts doubt on its backers' claims that doctors' work could suffer if they do longer hours. “If you work in portions of 12 hours with a rest in between, you won't burn out. 60 hours means 12 hours daily from Monday to Friday with a work-free 2-day weekend. It's normal”, he says. And he warns that if the government does impose the new limits doctors will either get round it or simply follow colleagues to western Europe where they will be better paid even if they do work less hours. “If the government limits the number of working hours, it should raise the wages of doctors. But wages are still low. Doctors are leaving Lithuania and will be leaving in even greater numbers if this working hours limitation becomes a reality. “I work the time that I need. Doctors can change shifts with colleagues and can work in different places. No one counts my working hours for instance”, he says. The proposed amendment has already provoked discussion among the general public who fear it could lead to doctors heading off to western European EU countries for work, leaving a lack of quality doctors in a health sector they say already suffers from a shortage of good physicians. Jonas Sakalauskas, 53, who lives in Vilnius is at the Emergency Hospital visiting a relative. He said that while the hospital is reasonably well-equipped and has good doctors at the moment, many of the best physicians are leaving. “Since Lithuania joined the European Union last year, many fields of medicine now lack doctors who went westwards”, he says. He explains that he had a surgeon friend who left Lithuania to work in Norway on a long-term contract because of the poor working conditions in Lithuanian hospitals. In towns outside the capital the situation is worse. Paulina Rediska, 25, lives in Visaginas, a town in eastern Lithuania in the shadow of a nuclear plant soon to be closed under EU requirements. She says: “It's a terrible thing having to go to our hospital. You come in with a splinter, yet you checkout after undergoing cranial trepanation. I have come across real horror stories from there from my friends and relatives.” “For instance I know of a girl who was prescribed tablets which were categorically forbidden for her—she ended up having to be treated in hospital for weeks; my 7-year-old brother fell and knocked himself out at school playing in the playground during break and the doctors just gave him some stitches for his cut and then told him to walk home on his own in the middle of winter. They didn't even check him for concussion. Then later they misdiagnosed a broken finger he also had.” Low wages seem to compound the seemingly grim situation in many hospitals and doctors desperate to earn more than the €350 (US$455) average monthly wage for a physician in the country ask patients for extra payments to ensure good service. As in many other former communist bloc countries, polls suggest bribery is rife. According to a recent poll of Vilnius residents, 63% of respondents said they had been asked to give bribes at the capital's Maternity Hospital while 92% said that bribes had helped them to solve problems at hospitals. Government representatives declined to comment on the amendments when contacted by The Lancet, but an official at the Lithuanian Health Ministry, Vytautas Radavicius, told local media: “This is currently being dealt with by the Ministry of Labour and Social Care and our ministry has yet to formulate a final response to it.” Until then working hours and hospital conditions for doctors and their patients will stay as they are. “People say local doctors are bad and all the good ones have already left for Ireland, the UK, or Sweden. But what if something bad happens to you? Who will give you urgent treatment?” says Ausra Vozykaite.