Norman Briffa argues that separating training from service will produce competent surgeons within the European Working Time Directive

The Department of Health believes junior doctors should be allowed to opt out of the European Working Time Directive, which limits the number of working hours to 48 a week.

The independent Working Time Regulations Taskforce, which was set up by the DH, reported on its investigation into the effect of the directive on doctors’ training.

The DH then pledged to help junior doctors opt out of it.

‘When changes that reduce the total time of specialty training were introduced, catastrophe and Armageddon were predicted’

The taskforce was chaired by Norman Williams, recently retired president of the Royal College of Surgeons.

Meanwhile, the Royal College of Surgeons in Edinburgh, through its president Ian Ritchie, issued a press statement disagreeing with the conclusions that opt out should be considered for surgical trainees.  

Hearts and minds

I am a consultant cardiac surgeon. My training over nine years often involved working 100 hours or more in a single week.

When the working time directive was introduced in 1993 (towards the end of my training) cardiothoracic surgical trainees managed to get a limited opt out from the 48 hour week.

‘The BMA argued long and hard for shorter working hours for doctors’

This opt out was colloquially known as the English clause - named not after the land of St George but after Sir Terence English, a cardiothoracic surgeon and president of the Royal College of Surgeons of England (1989-1992).

The opt out did not please the British Medical Association, which had for years argued long and hard for shorter working hours for doctors.

When changes that reduced the total time of specialty training were introduced, catastrophe and Armageddon were predicted by quarters in the surgical hierarchy.

Long hours

A 2004 article in BMJ, authored by cardiac surgeons, explained how these changes and the directive had resulted in a drastic cut in the total number of surgical training hours.

Malcolm Gladwell, the modern day sage reminds us in his book Outliers that excellence in any field - whether it is music, science or surgery - is not inbred, but requires 10,000 hours of practice.

Until fairly recently, surgical training was predominantly an apprenticeship, and in apprenticeships hours spent on the shop floor is what is required to achieve competence.

‘Training and assessment of surgical trainees has undergone radical changes’

In recent years, training and assessment of trainees have undergone radical changes, partly as a response to the imposition of shorter hours but also because of the general professionalisation of training and assessment.

A recent paper from Papworth Hospital in Cambridge (one of my training alma maters) confirms the point that the directive has not adversely impacted the quality of cardiothoracic training.

One of the paper’s messages was that large institutions such as Papworth provide opportunities for trainees that may not be available in smaller institutions.

My position on the 48 hour working week and its effect on surgical training has changed: in my view Professor Williams and the DH are wrong, and Mr Ritchie is right.

There are provisos to my change of heart. For surgical training to prosper within the constraints of the directive, the following conditions should apply:

  • Professionalisation and technological improvements in methods of training with increased use of simulation should continue apace.
  • Not all consultant surgeons should be trainers.
  • Medical surgical trainers should do less service work. This may seem contentious. All directorates in my hospital (and I imagine in all others) have nurse educators. Their job is to educate. They do little or no service work. Yet the same arrangement on the wards and in operating theatres does not exist for medical staff.
  • Trainee doctors should do less service work.
  • Not all hospitals should have trainees.

This last statement is the hook that involves NHS England chief executive Simon Stevens in this debate.

In a speech to the NHS Confederation in June, Mr Stevens questioned a long accepted norm in the NHS: that all acute hospitals must have trainee doctors.

Taking junior doctors away from hospitals would require a considerable investment to create and hire the workforce to replace them.

‘Which type of tenured non-training doctor is required to do the bulk of the work is a vexed question’

No doubt the BMA would insist on an increase in consultant numbers. Under current financial arrangements this is unlikely to happen.

In my view, what needs to happen is an increase in the number of nurse and surgical care practitioners. In many US hospitals attending physicians and physician assistants do most of the work.

Professional limbo

The influence of his time in America is clear to see in Mr Stevens’ thinking.

Our health secretary, Jeremy Hunt has announced that there is to be a big increase in the number of physician associates – the English equivalent of physician assistants.

In the UK, surgical care practitioners are often in professional limbo. They typically train in an unrelated healthcare field and then move sideways because of a lack of professional fulfilment or opportunities. 

In the UK, only three universities provide degree level courses for surgical care practitioners.

‘The old district general hospital remains the mundane workhorse of the NHS’

If Mr Stevens wants genuine, radical change in what he calls the “physiology of the NHS”, hospital trusts, the NHS generally, Health Education England and institutions of learning must grab this opportunity to expand the population of practitioners in a way that serves the service.

New representative bodies will have to be created to ensure independent professional pride for these healthcare workers.

A missing part of the jigsaw is the vexed question of which type of tenured non-training doctor is required to do the bulk of the work: the traditional consultant or something completely different, less British and more European maybe?

Two speed NHS

The creation of this new NHS will, in many peoples’ eyes, create a two tier system: teaching hospitals in large cities will become ivory walled centres of excellence, with all the trainees and glamorous high tech medicine, while the old district general hospital remains the mundane workhorse of the NHS.

‘The creation of this new NHS will create a two tier system’

I seem to recall that this is how it used to be before the democratisation and the granting of teaching hospital status to all and sundry by Tony Blair and his health advisers.

These changes will not be easy to achieve.

If sustainable, high quality training of all healthcare workers to provide first class care is to be achieved, there is no alternative to radical change.

This is the challenge for Mr Stevens and others leading the NHS.

Norman Briffa is a consultant for Sheffield Teaching Hospitals Foundation Trust