Training ‘compromised’ by time directive

 Surveys by the Association of Surgeons in Training and the British Orthopaedic Trainees Association (BOTA) have highlighted serious concerns over the implementation of the European Working Time Directive (EWTD). The overwhelming message from respondents has prompted the Royal College of Surgeons and BOTA to issue warnings that the safety of patients, quality of care and standards of surgical training are being compromised. As hospitals prepared for the full implementation of the EU regulation to reduce doctors’ hours to 48 hours per week, by August 2009, the Royal College of Surgeons reported that unsafe levels of staffing are already starting to be experienced, as the UK is running out of available surgeons to fill the gaps in NHS rotas. The College said that the full extent of the problems is being hidden by some NHS Trusts, who are employing their own doctors as locum cover, and pressurising trainees to falsely report their working hours. A survey of over 1,000 surgeons by the Association of Surgeons in Training (ASiT) shows significant underreporting of hours worked by trainees as NHS Trusts struggle to meet the new restrictions. Key findings, published by the Royal College of Surgeons in the report: Optimising working hours to provide quality in training and patient safety, included: • 90% of trainees are exceeding their rostered hours on a weekly basis. • 85% reported coming in to perform operations on their days off. • Only 25% felt that the working patterns held by their human resources departments accurately reflected their actual working hours and 55% reported being pressured to falsely declare their actual hours worked. • 68% reported deterioration in the quality of training and operative skills as a result of shift-working patterns brought in to meet working time regulations and 71% felt the reduction in working hours had not led to any improvement in their work/life balance, with 74% reporting that new shift patterns had led to pressures on social relationships.

Support for opt-out

ASiT believes 65 hours a week is required to gain the necessary training opportunities and 80% of respondents would support an opt-out of the European Working Time Regulation (EWTR) to protect training. The College’s regular monitoring of junior doctor training quality shows that trainee surgeons are not able to get into theatre to learn. Almost half of junior doctors in the first two years of surgical training go to theatre fewer than three times a week and one in 15 does not go at all. “This is a worry for today and tomorrow,” said John Black, president of the Royal College of Surgeons. “On the one hand, the immediate effects on patient care in the NHS are potentially disastrous. There are simply not the surgeons in the UK to fill the gaps. On the other, trainees are telling the college they cannot gain enough experience to progress on the shortened hours. The choice for the nation is clear – do we want patients of the future to be treated by a group of highly skilled and experienced surgeons, or be passed around a wider group of lower-skilled surgeons with less experience?” Ben Cresswell, the president of ASiT, added: “The increased tendency to shift working that we have seen over the past few years has been driven entirely by a desire to reduce hours. That desire has not come from the profession, neither from trainees nor from consultants, and the hours reduction has been universally damaging due to significant fragmentation of the surgical team and a loss of continuity of care. “We now have hard evidence that this fragmentation has harmed both quality of training and patient safety. The Association of Surgeons in Training is offering its full support to the Royal College of Surgeons of England, in its request for an opt-out of the EWTR legislation. We feel that such a concession offers the very best solution, in order to permit a return to excellence in training and to protect high quality patient care.” The College called on the Government to put in place a long-term solution to safeguard patients and the training of future surgeons. Key recommendations include: • The introduction of an opt-out for all the surgical specialties in England, to allow hours to be worked up to the figure defined by the College’s trainee organisations. • The revision of the rest-break legislation. Formal rotas brought in to meet working time legislation have introduced unsafe levels of handovers between doctors and have proved more disruptive to work-life balance than the longer on-call system they replaced. The College pointed out that the US has decided to keep junior hospital doctors’ weekly hours at 80, largely based on patient safety grounds. In Germany, the trade union representing hospital doctors in conjunction with the professional bodies has agreed that 61 hours is appropriate.