Significant changes will be considered so doctors can train and work more flexibly, the Government announced today. These changes will be explored in response to an independent review of the impact and implementation of the European Working Time Directive on the NHS and Health Professionals.
Following an independent review on the impact and implementation of the Directive on the NHS, work is now underway to explore options to support doctors who want to access more training opportunities. Former President of the Royal College of Surgeons (RCS), Professor Norman Williams led a taskforce of experts, including the BMA, NHS Employers and Royal Colleges, which reported to the Government in April with a range of recommendations.
Under the Working Time Directive, doctors and trainee doctors are restricted to working a maximum of 48 hours per week on average over a six month period, unless they voluntarily opt-out. Within the NHS this has contributed to overly rigid shift patterns, affecting time for training.
The taskforce report found that the Directive has had a beneficial impact by preventing doctors from working very long hours and jeopardising patient safety. However, it also found that doctors in certain specialty areas, such as surgery, work longer hours voluntarily to gain the training they need. For example, doctors beginning surgical training today will have 3,000 fewer hours to learn through training – equivalent to 128 whole days. In addition, complex shift patterns can increase handovers between doctors, which can increase the risk of errors, and enforced rest breaks have resulted in cancellation of some clinics.
The Government is today accepting all of the review’s recommendations and has committed to explore all options including:
Identifying training time that is not working time: at present doctors must complete training and regular work within the 48 hour weekly limit of the Directive unless they opt out - Health Education England will explore if and how some training elements could be separated from work related activities, meaning doctors can have more opportunities to train outside of their regular duties and improve their skills.
Raise awareness of the voluntary opt-out: The Department of Health will consider ways to encourage more widespread use of the individual right to opt-out of the 48 hour restrictions for those who wish to, and where it is safe to do so. This will allow doctors who want to spend extra time on work related training activities to do so. This would be particularly beneficial in some specialities such as surgery.
Review working patterns and rotas: Health Education England (HEE) is working on a national programme that will provide support to Trusts so they can redesign staff rotas and give doctors more time to access training.
The Government will also ensure that the current contract negotiations for junior doctors and consultants take account of the recommendations of the report, including how training time can form part of working patterns and that doctors have appropriate rest times and breaks.
Secretary of State for Health Jeremy Hunt said:
We share the longstanding concerns about the impact of the implementation of the Working Time Directive on patient care and doctors’ training. Doctors should have the flexibility they need to access the training they want. This would lead to better care.
We will never go back to the past with tired doctors working long hours, but it is clear that the Directive does have a negative impact on the training of doctors in some specialities. We will now look at how training and working time could be separately identified so we can give doctors the flexibility they need.
Professor Norman Williams, Chair of the independent taskforce, said:
As a taskforce we were clear that the one size fits all approach of the Working Time Directive in medicine is detrimental for training and patient care in some specialties. Our recommendations set out a clear path to getting to much needed solutions. The taskforce, which drew support from across the health service, was unified that action is needed now but solutions should not lead to a return to doctors’ working excessively long hours.
I am pleased the government has accepted our report and committed to explore our key recommendations. In particular the separation of training and education of trainee doctors from their work on the wards has the opportunity to strike the right balance between delivering patient care and ensuring that junior doctors have the right knowledge and skills.
Although the future of the Working Time Directive is not currently being negotiated, the European Commission is carrying out an impact assessment, including looking at options for new proposals. The problems identified by the independent taskforce related to the way the Directive has been implemented and particular court judgements that have had an effect, since the Directive was negotiated.
The six recommendations that have been accepted are that:
The NHS should review best practice in the design of working practices, and share examples of the successful delivery of patient care and the training of junior doctors.
The findings of the report will need to be taken into account in the on-going contractual negotiations.
The specific challenges faced by some specialties should be addressed in further work.
More consideration should be given to encourage wider use of the right for individual doctors to opt out of the current restricted hours.
The possibility of creating protected education and training time for junior doctors should be explored.
The lack of flexibility brought about by the court judgments is tackled, whilst ensuring doctors don’t suffer undue fatigue.
Members of the taskforce included:
Professor Norman Williams, President, Royal College of Surgeons (Chair)
Andrew Beamish - President, Association of Surgeons in Training
Andrew Foster CBE - Chief Executive of Wrightington Wigan and Leigh NHS FT
Chris Hopson - Chief Executive, Foundation Trust Network (FTN)
Dean Royles - Acting Chief Executive, NHS Confederation and Chief Executive, NHS Employers
Dr Diana Hamilton-Fairley - HEE representative and South London LETB, Director of Education & Quality
Dr Clifford Mann - President, College of Emergency Medicine
Dr Hilary Cass - President, Royal College of Paediatrics and Child Health
Dr Kitty Mohan - Co-chair, BMA Junior Doctors Committee
Dr Patricia Wilkie - President, National Association for Patient Participation
Dr Paul Flynn - Chair of the BMA Consultants Committee
Dr Ted Adams -Academy of Medical Royal Colleges Trainee Doctors’ Group
Professor Patricia Peattie - Academy of Medical Royal College Lay Advisory Group
Professor Terence Stephenson - Chair, Academy of Medical Royal Colleges
Sir Richard Thompson - President, Royal College of Physicians.
The NHS spends £5.5 billion annually on consultants’ pay and the £3 billion spent on the pay of doctors in training. The government is currently in negotiations to modernise the contracts and ensure that doctors have the right training and rewards to look after patients from the moment they are newly qualified until the day they retire as an experienced consultant.
Health Education England’s Better Training Better Care (BTBC) programme was established to improve both the quality of training and patient care. Pilot sites run as part of the BTBC programme have demonstrated the ability to improve patient care and safety by increasing Saturday and Sunday discharges and reducing the time it takes to refer and assess patients, while at the same time saving money. HEE is now working with other organisations to roll out the pilot site learning and improvements nationally.
An example of one pilot area is East Kent Hospitals University NHS Foundation Trust. They carried out a programme with the aim of improving training for junior doctors by enhancing their supervision out of hours and at weekends. They found that some junior doctors were being left exposed at these times without the supervision they needed. As a result they redesigned rotas with different teams to ensure that doctors were not being drawn away to wards. By creating new teams and rotas it meant that trainee doctors could enhance their learning experience on different areas during their working hours, whilst keeping in contact with their supervisors.
Full details of the 16 Better Training, Better Care pilots.
Full terms of reference for the Taskforce report.