The chair of the British Medical Association consultants' committee recently suggested that the problems posed by the European working time directive could be solved by employing more consultants and ensuring managers work closely with clinical colleagues.

However, I think trusts would be better off relying on the hospital at night methodology, in which effective clinical care is achieved by having one or more multi-professional teams who between them have the full range of skills and competencies to meet patients' immediate needs.

While it is generally agreed that trusts may need to employ more junior doctors to comply with the directive, it is difficult to see how additional consultants will help significantly.

This group cannot and should not be expected to fill in for missing junior doctors. Such an approach would be an expensive and inappropriate use of consultants' time, and could damage the training provided to juniors. Worse still, it could perpetuate the reliance on juniors to carry out inappropriate tasks.

Radical solutions

The problems created by the working time directive are not going to be solved at this late stage by radical solutions. Not only is there not enough time to develop such plans, but the evidence suggests it is the hospital at night concept, as advocated by the national workforce projects group for the past five years, that offers the best option for trusts.

Over half the rotas in England comply with the 48-hour limit. Most of them have achieved this by objectively eradicating inappropriate work, improving the way out of hours care is delivered by juniors, developing closer working ties between various healthcare and administrative groups, improving IT systems and employing more doctors (once all other solutions have been exhausted). From our experience, trusts that rigorously implement these measures are best placed to comply with the directive.

No-one would disagree that an open and honest relationship between managers and clinicians is vital if a trust is going to crack the directive. However, the above findings suggest this relationship forms just one part of a more complex, collaborative approach between many staff groups in a trust.

Valuable contribution

To comply with the directive, managers and clinicians will have to forge and maintain closer ties with nurses, clinical support staff and IT and administrative staff. Failing to recognise the valuable contribution these groups make will undoubtedly perpetuate a long hours culture among doctors and feed the belief that only "innovative" solutions will suffice.

However, it is important to recognise that positive collaboration between clinicians and managers will always be difficult when reducing doctors' hours will also reduce their pay.

Juniors need to acknowledge that their pay was always going to fall with the imposition of the directive and a low hours culture on trusts. This outcome was predictable in 2000 when the new pay system was approved by the BMA. While acknowledging this fact may be a difficult pill to swallow, it will help both parties focus on the key problem of designing sustainable, compliant rotas that meet the training needs of doctors and ensure a healthy work-life balance. However, any failure by managers and consultants to sensitively handle the issue of less pay will significantly damage the morale of juniors and could jeopardise the long-term prospects of any new working arrangements developed by both parties.

At this late stage, innovative solutions will struggle to deliver compliance by next summer. The best outcome rests in the tried and tested measures of multi-professional working across 24 hours, service reconfiguration and, where absolutely necessary, additional junior doctor posts. However, any additional medical posts must be sustainable from a workforce planning viewpoint. These approaches have been shown to work and offer the best chance of improving junior doctor training in the face of reduced working hours.

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