Introduction
European working time directive became part of UK law in October 1998 as health and safety legislation.[1]The law meant to reduce the doctors time in hospitals concerning the patient and doctors health . At that time junior doctors or doctors in training (DIT) were excluded from the scheme due fear of the adverse effects on hospitals .But in may 2000 the agreement was reached between European parliament and council of Ministers on agreements and timetable for doctors in training to be included within directive .The directive will be applied to DITs as follows
- 1 August 2004: maximum 58 hour week. All rest periods apply
- 1 August 2007: maximum 56 hour week
- 1 August 2009: maximum48 hour week (if introduction of the48 hour week is deferreduntil 1 August 2012, then a maximum52 hour week will comeinto force on 1 August 2009[1]
But DITs , NHS and consultants are reluctant in following the directive or are trying to make some way out . I will discuss about their apprehensions later but first I will discuss the health and safety problems related to long working hours on doctors and patients health.
Effects on doctors health
Working long hours have adverse effects on DIT health . As soon as junior doctors enter into hospital workforce they have to take decisions which have direct implications on patient life and safety , they also have to maintain good working relationships with other medics, nursing staff and administration for ensuring the better care of their patients health. DITs also have to maintain balance between hospital life, social life and personal life.[2] Sleepless nights have direct effect on DITs health. Sleep deprivation causes fatigue which can lead to fatal mistakes by doctors . One study in USA compare 2 groups of doctors in same hospital . One group was doing long hours of duty and other with short hours of duty with good supporting cover. They find that doctors with long hour of duties commit serious mistakes than the other group [3]. Sleep deprivation causes reduction in general quality of life, less motivation, poor work output and increased risk of accidents [2].
Effects on patient care
Continuous wakefulness and moderate alcohol consumption have same effect on body [4]. This effect maximizes at the end of night shift, which is time for drive to home, and this increases the risk of accidents. Fatigue also forces the DIT for short cuts, which can threaten the patient life. Long hours of working also affect the doctor–patient relationships. One study in Birmingham university medical school (UK), 39% junior doctors indicated that long hour adversely effect their work efficiency and 28 percent indicated that long working hour are effecting patient relationships [5]
I personally agree with all these findings. I used to work in my house job from 90-112 hours per week and I experiences all these adverse effects mentioned above. On few occasions I also commit some serious mistakes, which I still regret. Hospital management should also take in to account that all doctors do not have same stamina of working and some may feel tired after few hours of working or they might be suffering from a disease which can effect their performance.
The Ditz were excluded in 1998 on the basis that it would cost much to hospitals as Ditz are 38 percent of hospital workforce. But when the actual cost calculated after DITs inclusion it only makes difference of 1-4 percent[6]
Hospitals that reduce working hours can improve their business because it increases effectiveness in work thus increases the overall quality of care, Improved working relationship among team members; doctors show decrease resistance to administration to new initiatives due to general environment of goodwill[2].
Effects of European working time directive.
The EWTD will have more profound effect on the hospitals , junior doctors, and consultants[7]. Small hospitals now have to hire more junior doctors in their limited budget.
But junior doctors may not be able to get more patients and will have effect on their training and small hospitals might have to close or merge in larger hospitals to provide more patients to doctors . but it would have political implications too[7].
Some specialties like accident and emergency will not be affected as they are already following the shift system but in some specialties like pediatrics and maternity wards, which are often hectic, and need night cover will be hit hard.
Junior doctors especially in surgical field feel that it would have detrimental effect on their training and fear that training period might extend. Because they will be doing few procedures in a limited time. EWTD will also effect the continuity in patient care. if a doctor is managing patient for more than 24 hours then it helps in creating the environment of trust between patient and doctor[7]
Extensive postgraduate training will not be achieved and there might be move to provide more frequent training programmes that which will ensure that trainee has got appropriate training in hand just in time ) instead of trained some time ago which he rarely or never performs. [8]
If we look at the experience of Dutch in implementing the EWTD-NT . They also face some difficulties like submitting the hours of duties by hospitals(60 percent of hospitals were not able to submit appropriate record), no compensation for home based on call and above all non-compliance by hospitals [9].
There are also some provisions in EWTD-NT which cause confusion among DITs Among them is confusion regarding rest period and not including the education and training time in working time .
Non-compliance by many hospital trusts is also a problem .Many hospitals will have to hire many junior doctors and it will increase the burden on hospital management and on funds. Under the terms trust who fails to cut the number of hours of doctors will face fines and threat of employment tribunal .Currently 16- 40 percent UK DITs are working working above the 56 hours a week or without adequate rest period[10].
Percentage of PRHO (Pre-Registration House Officer), SHO (Senior House Officer) and SpR (Specialist Registrar) posts breaching working hours limits. The figures are based on returns for November 2003:
| England (Sept 03) |
Wales (Nov 03) |
Northern Ireland (Nov 03) |
Scotland (Aug 02)* |
|
| PRHO | 92% | 100% | 94% | 81% |
| SHO | 85% | 61% | 68% | 41% |
| SpR | 80% | 40% | 50% | 41% |
| Total | 84% | 60% | 72% | 50% |
- · Total New Deal compliance in Scotland for August 2003 was 73%; figures by grade were not available.
Table source = [10]
Solutions to problems .
There should be a basic change in health care delivery system .Instead of providing health care service to every corner of country will not guarantee good health care so there should be centralization of health care services so that people get health service at some distance but of high quality. consultants are also reluctant to follow EWTD because of long tradition of not working out of hours in hospital. They have to change their behaviors in compliance with new directive[11]
There is also need for more doctors in UK .In recent years there has been surge in doctors from developing countries (especially from India) by passing the PLAB (The Professional and Linguistic Assessment Board) exam conducted by GMC . But it also raises the issue of brain drain in developing countries as they are already deficient of efficient doctors. So there is an urgent need of increasing the number of medical schools but it will take 4-5 years to replace any gap. There is also plans of learning the multiple skills by doctors and nurses to share the load of other specialities
Pilot projects
Hospital at night concept[12]
Currently 19 hospitals are running pilot project of “hospital at night” in England. The hospital at night was original concept of Dr.Elizabeth Paice ,Dean Director for London Deanery . the aim of project was to alleviate the effects of full shift working , brought about by EWTD In this project nursing staff takes the responsibilities of junior doctors and work as a team with senior registrar and consultants . Team also share the burden of other specialities which are going heavy. There has been mixed response for this project some junior doctors feel that they have to take orders from senior nursing staff and they work as clerks and technicians instead of doctors. Some are skeptical about giving the nurses the role of doctors as they are trained differently and some patients wishes to be seen by doctors instead of nurses. Nurses take more power from setting up ventilators to prescribing antibiotics. It also means that workload during night will increased . it facilitates junior doctors to do some other things like going to operation theatre and they do not have to be present all the time in wards[12].There is also use of modern IT tools for working at night like mobile phones ( time saving), electronic patient record reduces the margin of error and rapid approach to patient problem) and telemedicine( in which the on call consultant from home can diagnose the cases and can give advice).
Conclusion .
EWTD will change the way the hospitals work so it will take time to all concerned parties to accept this change .Like every law ,EWTD is not the perfect solution for everyone [9].So hospitals and doctors have to adjust themselves with the new realities. As there is no way out of this law .EWTD is still achievable as other countries (Dutch) are following the EWTD. There are some problems but they will be solved with time and policy makers should make some amendments regarding the controversial points.
Long hours of working were part of DITs life but now importance of patient and doctor health safety prevails In my personnel view as EWTD is a very good law and all concerned parties should try to implement this in full strength . Although it will take some time to understand the full implications of this directive .regarding the decrease training opportunities for surgical doctors in training , this issue must be resolved as first priority by collaboration of DITs ,consultants and BMA.If this issue is not resolved early
then it can cause increase efflux of DITs from UK which will further reduce the number of doctors in UK. Compliance of hospitals to EWTD should be monitored regularly.
References
1.Sally .W. Inquiry into the European Working Time Directive (EWTD) – evidence from the BMA
House of Lords Select Committee on the European Union Sub-Committee G (Social Policy and Consumer Affairs)
February 2004[online].Available at http://web.bma.org.uk/ap.nsf/Content/ewtd0204.[accessed on 11 nov 2004]
2.ANDREW .L. Safe working hours – doctors in training
a best practice issue[0NLINE] AHR Article – December Vicdoc.Available from http://esvc001390.wic013u.server-web.com/AHR%20-%20second%20last%20draft.pdf [Accessed on 13 dec 2004]
3.Christopher P. Landrigan, M.D., M.P.H., Jeffrey M. Rothschild, M.D., M.P.H., John W. Cronin, M.D., Rainu Kaushal, M.D. Effect of Reducing Interns’ Work Hours on Serious Medical Errors in Intensive Care Units. N Engl J Med 2004 Oct 28; 351:1838-48.
4.Dawson D & Reid K 1997, ‘Equating the performance Impairment Associated with Sustained Wakefulness and Alcohol Intoxication’ (pre-press manuscript), Centre for Sleep Research, School of Psychology, University of South Australia.[online].available at http://cf.alpa.org/internet/projects/ftdt/backgr/Daw_Lam.html.[accessed on 17th dec 2004]
5.Samkoff JS & Jacques CHM 1991, ‘A Review of Studies Concerning Effects of Sleep Deprivation and Fatigue
on Residents’ Performance’ Journal of Academic Medicine, November vol 66 no 11, pp687-693.
6.Australian Medical Association Limited 1995-2000, ‘Overseas Experience in Regulating Hours of Work of
Doctors In Training’ Part 2 – Detailed Country Profiles.[online].Available at http://www.ama.com.au/web.nsf/doc/SHED-5G2V8T.[Accessed on 17th dec 2004]
7.Lynn .E.The European working time directive: the final countdown
BMJ Career Focus, Jun 2004; 328: 229.
8. Sir Graeme C.Education and training within the European Working Time Directive.BMJ Career Focus, Aug 2002; 325: S69.
9. Fleur .S.The Dutch experience of implementing the European Working Time Directive.BMJ Career Focus, Aug 2002; 325: S71
10. Hospital doctors – junior doctors’ hours
May 2004[online].BMA .avaliblnle at http://www.bma.org.uk/ap.nsf/Content/ewtd0204.[accessed on 15 dec 2004]
11. Paul Thorpe. Implementing the European Working Time directive on a national level. BMJ Career Focus 2002;325:67 (31 August).
12. Rhona MacDonald.The Hospital at Night.MJ Career Focus, Jan 2004; 328: 19.