EUROPEAN WORKING TIME DIRECTIVE FOR JUNIOR DOCTORS

Mr P R Shah, S Raman and E Vaughan-Williams

Abstract

Objectives: To gather opinions of junior doctors regarding the current system and future of the European working time directive (EWTD).

Method: A questionnaire study on new deal system (EWTD) was circulated to all doctors below the grade of Registrar in a District General Hospital in February 2003.

Results: In all 62 junior doctors (80%) responded. The median interval of training from their primary medical qualification (MB, BCh) was 42 (7 -144) months. The respondents were equally distributed between medical (31) and surgical specialities (31). The majority (95%) of junior doctors were aware of being compliant. However, only half of them knew about income depreciation. 75% of surgical trainees preferred to be non-compliant in comparison to 32% of their medical counterparts (p < 0.001). 65% of surgical trainees felt that clinical exposure will be decreased after implementation of EWTD, in contrast to 35% of medical colleagues (p < 0.05). 70% of the junior doctors were concerned about the increase on the workload of registrars and consultants and feared its negative impact on the training of junior doctors.

Conclusion: EWTD will shake the foundations of surgery in the UK and affect continuity of patient care. Surgical trainees will have to work with restricted hours at the cost of their training.

Keywords: European working time directive, junior doctors, Banded pay system, New Deal

Introduction

In the United Kingdom, the Royal Colleges have been insisting on reducing the working hours of junior doctors for a long time. The European Working Time Directive (EWTD) was designed to protect the health and safety of workers by restricting the number of hours an individual can work and imposing minimum rest requirements on all workers. 1 The directive was introduced to the United Kingdom in 1991 with the objective of reducing the working week to 56 hours.2 This objective has not been accomplished nationally over the last 12 years.

The NHS has traditionally run on multiple tiers of resident doctors with consultants being on-call from home. However, this pattern is unsustainable under the EWTD. 2 From August 1998, junior doctors in National Health Services and other health care systems throughout Europe are no longer excluded from the provisions of EWTD. 3

Over the last few years, efforts have been made throughout the NHS in the implemention of the directive and its application to junior doctors' working hours. We conducted a questionnaire survey in our hospital to examine current job plans, evaluate awareness of the EWTD by junior doctors, differences in view between medical and surgical trainees and views of future implications of the directive.

Methods

A questionnaire was designed to ascertain the basic knowledge of EWTD and its implications. This was distributed to all junior doctors in a district general hospital in February 2003. Only doctors below the grade of Registrar were included in this study. The doctors were contacted both personally and by telephone and nature of the study was explained to them individually. All replies were received anonymously. Data was collected regarding their experience as a junior doctor, speciality, their current rota or shift pattern, their knowledge of EWTD and views on its implications. The results were tabulated into an Excel database, and statistical analysis was performed using "chi-square test" with a "p-value < 0.05" considered to be statistically significant.

Results

The questionnaire was sent to all junior doctors (n=75) below the grade of registrar in the hospital. Replies were received from 62 doctors (83%), with median age of 28 (Range 24-42) years. The sex distribution among the doctors who responded was similar. The median interval of training since their primary medical qualification (MB, BCh) was 42 (range 7 -144) months. There was equal distribution of respondents among the medical and surgical specialities. The medical specialities considered in our study included doctors from general medicine (22) and paediatrics (9). The surgical specialities comprised doctors working in general surgery (9), urology (2), orthopaedics (5), ENT (3), accident and emergency (2), anaesthesia (2), ophthalmology (4) and obstetrics and gynaecology (4).

In our study, 31 doctors receiving Band 3 salary were identified to be non-complaint with the directive's guidelines and 31 junior doctors receiving Band 2A or 2B were noted to be working on full or partial shift. Among the respondants to our questionnaire, 12 (20%) were senior senior house officers (SSHO), 42 (68%) senior house officers (SHO) and 8 (12%) pre-registration house officers (PRHO).

A total of 59 (95%) junior doctors were aware of the necessity of being compliant as part of the new deal system. However, only 29 (47%) knew about income depreciation subsequent to implementation of the EWTD.

Interestingly, 75% (23/31) of surgical trainees preferred to be non-compliant and desired to receive Band 3 pay in comparison to 32% (10/31) of their medical counterparts (p < 0.001). Not surprisingly, 65% (20/31) of surgical trainees in contrast to 35% (10/31) of medical colleagues felt that implementation of EWTD would decrease their clinical exposure and training (p < 0.05).

70% (44/62) of the junior doctors were concerned about the increase on the workload of the registrars and consultants after implementation of EWTD. 75% (47/62) agreed on its potential negative impact on their training owing to decreased attendance at educational activities in the new shift system. The majority also feared a consequent increase in duration of their training period.

84% (52) junior doctors felt that their social life will be affected by the new system and 79% (49) junior doctors were against incorporating fixed annual leave in their partial or full shift. 35 (57%) junior doctors felt that there will be financial implication following implementation of EWTD.

Discussion

The European time working directive is not a gentleman's agreement but a law enacted in October 1998.3 The NHS has established nation-wide task forces and committees in an effort to be fully compliant by 1st August 2004. Non-compliance however remains a major problem is as also evident in other European states like Netherlands where it was introduced in 1993.4

Our study has shown that junior doctors in training are aware of the EWTD but lack knowledge of some of its implications. Surgical trainees prefer to be non-complaint and desire to work out-of-hours (i.e. more than 56 hours per week) as they feel that training and clinical exposure will be reduced by EWTD implementation. A similar result has been seen in a UK survery of medical registrars. 5 We also note that a majority of doctors in our study believe that the EWTD will certainly prolong their training. This is in agreement with a recent report which mentions that SHO training would be "just in time" rather than "just in case".6 The study by Chesser et al has shown that a registrar would take 8.45 years to accrue experience currently gained in 6 years upon implementation of EWTD 7 as a trainee would have spent less time with their consultant trainer.

In 1991, the Government, NHS Confederation, Academy of Medical Royal Colleges and the Junior Doctors Committee (JDC) of the BMA approved the "New Deal". It was meant to reduce the working hours of junior doctors in full shift to 56 hours of actual work per week or to 72 hours per week for the doctors on the on-call rota.8

Pay bands are determined principally by a combination of actual hours worked, on-call frequency, or the proportion of unsocial hours work and work intensity. All doctors working in posts which are non-compliant with the hours' limits and rest requirements of the New Deal will be placed in Band 3. Band 2 applies to posts which are compliant with the New Deal but where the actual hours worked are on average above 48 hours per week and Band 1 applies to the compliant posts with 48 hours per week or less hours of actual work.8

We feel consultants would be happy to note that majority of the junior doctor's in our study were concerned about the potential increase in the workload on senior colleagues. However, new strategies need to be developed to prevent this inevitable disaster! There has been concern of problems of workload and intensity in terms of increasing NHS waiting list. NHS would require 25% (1100 posts) new consultants and specialist registrars to a maximum of 334 national training numbers above 1999/2000 base line to cope with increased workload .7 Moreover, it is important to highlight that recruiting more doctors in order to comply with EWTD is not the most effective way of utilising financial and human resources. 9

With the introduction of shift system, social life and family commitments for doctors are likely to be affected. We feel the government should address this issue and new schemes have to be developed in the NHS without compromising health care in the era of EWTD.

Currently, pilot studies are being performed in various hospitals to consider role of medical support workers, specialist nurses, etc to find solutions for this new law. 1 Nevertheless, fundamental changes would be required to build a new consultant based NHS. 7

Conclusion

Implementation of European Working Time Directive in surgical specialities will be affected in terms of continuity of patient care and training of junior doctors. The surgeons prefer to be non - complaint and are against implementation of EWTD. We feel that EWTD may require modifications as per needs of different specialities and compliance to EWTD will be a major issue for many years to come.

Acknowledgement

We are grateful to all the junior doctors in Royal Glamorgan Hospital for their kind co-operation and prompt responses enabling us complete our study. We also thank Ms J Doble, Human Resources Officer at Royal Glamorgan Hospital for helping us to get the information about trainees in the trust.

References

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