Published: 14/02/2002, Volume II2, No. 5792 Page 24 25
In recent years, the number of hours worked by junior medical staff has been markedly reduced.
Meanwhile, many consultants are working above their contracted hours and the 48-hour maximum set by the European working-time directive.
1In July 2000, the government urged that 'chief executives should ensure the working-time regulations are fully implemented in their own organisations as a matter of urgency'.
2Research involving 300 consultants, published by the British Medical Association last month, showed they worked an average of 51.5 hours a week in the NHS.
3The study, which involved the consultants keeping a diary over one week, also showed they spent an average 3.3 hours per week on private practice or other non-NHS work, such as medicolegal reports.
Commenting on the findings, Dr Peter Hawker, chair of the BMA's consultants' committee, said consultants had expanded their working week to ensure that more patients admitted as emergencies were assessed by senior doctors. The nonemergency caseload had also increased with evening clinics and Saturday morning operating sessions to improve access and cut waiting times. 'These developments are positive for patients, but the toll on consultants has become unacceptable, ' he said.
The haematology directorate of the Royal Manchester Children's Hospital has devised a job plan for its three consultant staff, which reduces their hours without affecting patient care.
Analysis of hours worked Before the introduction of the new job plans, an audit of actual hours worked by consultants in the hospital was carried out. A total of 32 full-time consultants from 13 different specialties took part in the audit. Each kept an accurate diary of hours worked in the hospital. The diaries did not include time on-call from home. The diaries were completed over a period of between four and nine weeks (average = 4.2 weeks).
Analysis of the diaries showed that the average working week was 50.4 hours, compared to a contracted week of 35 hours and the working-time directive of 48 hours. In total, the 32 consultants who took part were working the equivalent of 46 full-time consultant contracts. If excess hours are unacceptable for junior doctors due to the risk of mistakes caused by fatigue and the loss of trained staff due to burn-out, it must be equally unacceptable for hospital consultants to work excess hours.
Methods must be found to reduce working hours without affecting the continuity of patient care to avoid premature loss of highly trained specialist consultant staff. This is in line with the approach taken to staff development and patient care in the NHS plan. In addition, it would improve the quality of care for patients, as it is self-evident that tired doctors are at more risk of making mistakes.
Changing job plans New job plans were drawn up for the three consultants working in the haematology department in a bid to find a solution which reduced working hours and maintained patient care. These job plans are being piloted and have been evaluated using a second, smaller diary audit.Hours worked before and after the introduction of the new job plans have been compared. In this analysis, as before, only hours actually worked in the hospital were counted, with time on-call excluded.
Analysis of the pre and post-change diaries showed a reduction in working hours, from 57 hours a week to 46.8 hours a week. This is significant, though still in excess of the number of hours contracted and the working time directive.
Significantly reducing hours worked should lead to a corresponding reduction in the risk of burn-out and premature loss of highly trained staff.
The changes The scheme involved the creation of a rest day by moving the two sessions normally scheduled for that day to two other days.
The result is two twosession days, two threesession days and one clear day. The old and new job plans are shown in the tables on this and the previous page.
A limited diary re-audit looked in detail at the effect of the job plan changes on one consultant, who kept an accurate diary of all work-related activities for nine weeks before and for nine weeks after the change to the job plans.
Comparison of the two periods showed a reduction in average working hours from 57 to 46.8 a week (despite three occasions in the post-job plan period when the rest day could not be taken as a result of covering the planned absence of colleagues). This is an improvement of 10 hours a week, taking the hours worked to just below the upper limit of the working-time directive, though they still remain about 30 per cent above those contracted for.
Several recent changes to the way the NHS delivers its services have meant an ongoing and significant increase in consultant workload, to the point where many are working in excess of those hours agreed as the maximum tolerable for junior doctors.
Though limited in scope, our work shows the benefit to consultant workload - without any adverse effect on the amount of direct patient contact - of shifting the sessions in individual job plans to create a rest day for each consultant taking part.
The new schedule is popular with those involved and the rest day seems particularly welcome in weeks when they are on call at the weekends.
The arrangement makes it possible to work more effectively without reducing the service to patients, or the cover.And it has not involved rescheduling clinics.When a consultant is required to be in the hospital every day, it seems more likely that they will work above their contracted hours.
We believe the scheme would be transferable to other specialties and teams, and would be effective in reducing their working hours and jobrelated stress.This may be of particular interest following current changes to the structure of the NHS, with the creation of new larger acute trusts and with the current review of consultants'working hours and contracts.
REFERENCES
1Council Directive No 93/104/EC, concerning certain aspects of the organisation of working time. 23 November 1993.
2Department of Health.
HSC 2000/025 Legislation: Human Rights Act.Working time regulations, parental and maternity leave regulations and part-time working regulations.
20 July, 2000.
3Consultants survey. BMA News. 12 January 2002:1.
Key points
Many NHS consultants are working more than their contracted hours.
Diaries kept by 32 consultants in one trust revealed an average working week of 50 hours.
A pilot scheme rescheduling the work patterns in a haematology department to include a rest day has reduced the number of hours worked.
The scheme is popular with consultants and could be transferable to other teams.
Dr Sheila Will is consultant in public health medicine, Bury and Rochdale health authority.Dr Andrew Will is consultant paediatric haematologist, Royal Manchester Children's Hospital.
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