Managers losing sleep as 48-hour week nears

Junior doctors’ hours may have slid off the political radar for the past few years, but they will be at the forefront of many NHS managers’ minds. By 1 August 2009 juniors should be working no more than 48 hours a week to comply with the European working time directive. Currently, they should work no more than 56 hours: a considerable improvement on the bad old days of 100-hour weeks.

An eight-hour drop will be a challenge and trusts will almost certainly need to make several significant changes to comply.

This will be done against a background of muted opposition from some doctors who, while not hindering implementation, are arguing that the directive has not made doctors’ lives better, may impact on patient care and should be scrapped. And some are suggesting junior doctors should use their individual right to opt out of 48 hours - as many consultants have done.

Roy Pounder, the Royal College of Physicians’ lead on the directive, says: “We would encourage junior doctors, if they wanted to, to sign the opt-out arrangements.” This would allow them to spend more time at hospital getting additional experience, and perhaps providing care.

Royal College of Surgeons president John Black describes the directive as a “nightmare” and says many European countries won’t bother to implement it. However, he says opting out would only work if all juniors in a trust did so, as there would otherwise be problems with rotas and pay. “Individuals should be aware they have this option, but there are complications,” he says.

One group of prominent consultants has argued that 48 hours is a “step too far” and called on the British government to renegotiate it.

Nephrologist Hugh Cairns, who is one of this group, says that despite the misgivings, senior doctors will be working to make rotas compliant. His own department at King’s College Hospital foundation trust in London has made two attempts to develop a compliant rota, but juniors are still unhappy with the proposals. “From next August we cannot write a rota which is satisfactory from the juniors’ point of view,” he says.

Seismic shifts

Earlier this year, a British Medical Association survey found 64 per cent of trainees were worried that compliance with 48 hours would have a negative effect on their training and a similar proportion felt specialty training should be extended.

Doctors’ concerns centre around continuity of care - which they claim is harder to achieve with a shift system - and the effect of shifts on trainees’ lives. Surgeons also have concerns that training may need to be extended, or juniors will get less experience of elective surgery. Some of these concerns are less to do with total hours than with the effects of two court rulings on rest periods and on-call time, which have driven the NHS towards a full or partial shift system.

But on the ground there is real progress towards the 48-hour target. The Department of Health says that monitoring indicates that about half of doctors in training are already working a 48-hour week. Progress should be more obvious this autumn, as many trusts will have introduced new rotas from this month.

Gaining momentum

“There is momentum in the right direction,” says David Grantham, project lead at NHS Employers, who points out that the NHS has had a decade’s warning of next year’s deadline. Many trusts seem to have appreciated the magnitude of the task: a 35-trust support programme offered by National Workforce Projects was oversubscribed and is now running a waiting list.

Other areas are determined to be early adopters, allowing time for fine-tuning. Around 90 per cent of trusts in the North West should be compliant from this month, says project director Yasmin Ahmed-Little. Strong involvement of junior doctors in each trust and at strategic health authority level, and the deanery, has meant that many trusts are already compliant.

The last major reduction in junior doctors’ hours was in 2004, when they came down to 56 a week. Compliance with this was helped by an increase in the number of juniors and a reduction by many trusts in the number of juniors required in hospital at night.

But there is evidence that compliance this time around will require trusts to use a combination of different levers, such as rota redesign, role changes among doctors and other staff, increasing staff numbers and looking at where services are provided. Professor Pounder says there is already only a “skeleton crew” in many hospitals at night and weekend.

A recent survey of obstetric and gynaecology and paediatric units found those that have achieved compliance had all made more than one change. But it also found that some units did not have plans in place to achieve compliance in time (news, page 10, 10 July).

Even those units that had plans tended not to have costed them, although finance was frequently cited as a potential problem area. Primary care trusts were allocated£100m in 2008-09 to help the NHS implement the directive, but this money was not ringfenced and it is not clear whether trusts are receiving earmarked funds.

There are potential savings for trusts that set up compliant rotas: they no longer have to pay junior doctors at enhanced rates. Research on early implementers has shown this can release funding for additional staff such as middle grade doctors and nurse specialists.

Tiers before bedtime

Paediatrics and maternity are two of the specialties that are expected to face the biggest challenges in getting to 48 hours.

In maternity, a rising birth rate has put additional pressure on the system and role substitution (using other staff to do some of the work historically done by junior doctors) is made harder by a shortage of midwives. “Hospital at night”, which involves cross-cover between different specialties, is also less relevant for maternity.

Most trusts now use hospital at night to some extent, but BMA junior doctors committee chair Ram Moorthy feels that there is still scope to improve. “We need to rationalise the number of tiers of doctors we have in hospital overnight,” he says. Some trusts have looked at whether very junior doctors need to be involved in night cover at all: having consultants on duty overnight can enhance patient care as well as release junior doctors for day duty.

Research led by Warwick University medical school has found that doctors working shorter rotas (those compliant with 48 hours) made significantly fewer errors than those on longer rotas. Better handover between teams on shifts may be important for care as well: some sites are looking at three nine-hour shifts to provide 24-hour cover with enhanced handover. This may help to address some professional concerns about continuity of care.

Another problem is recruitment of additional doctors: middle grade doctors such as specialist registrars are in short supply, and although training numbers could be increased, they would need to be offered career paths beyond the next few years. Using overseas doctors would be a solution but has become more difficult because of immigration restrictions.

Pressure to work

A BMA survey earlier this year found that half of juniors regularly experience pressure to work additional hours and two fifths regularly experienced a need to undertake training during rostered time off. Solutions will be introduced against a very fluid background - the full effects of Modernising Medical Careers and the surrounding recruitment problems are still working through, and many areas are reconfiguring.

A hard truth is that cutting hours will be difficult for smaller departments and may point inexorably towards centralisation of services: the royal colleges suggest 11-13 doctors would be needed on a full shift rota to provide 24/7 cover but also say that allowing each to work three “normal” days when training could take place.

Professor Pounder says: “Medicine is one of the largest specialties but only about a third of trusts have 13 suitable doctors. You can have a legal rota with seven or eight but it makes training and patient care very difficult.”

Further ahead, it could prompt reconfiguration of services. Dr Ahmed-Little says: “It may be that this is the catalyst to deal with the elephant in the room - that we can’t have all these sites providing surgery 24/7.”

Delaying tactics

The UK does have the right to apply for a derogation - effectively a delay in the implementation of the directive. Mr Grantham says this really would be only a delay and the Department of Health admits it may adopt this option on behalf of individual trusts that are struggling.

“An extension may be sought for parts of the NHS that need a little more time,” a spokesman says. “We will continue to monitor the situation as some smaller specialties and isolated hospitals may find meeting the deadline more challenging. As each trust is a legal entity in its own right, it would apply to the whole trust, although we would expect that all parts of the trust other than those specialties or locations with issues to comply, even though the trust had sought an exemption.”

Mr Grantham argues trusts will have to think imaginatively to find an answer that suits them - and stresses answers will vary according to locality and geography. For some hospitals, collaboration with neighbours may be important, but this will not be possible in all areas.

And there is scepticism that some trusts will adopt sticking plaster solutions. Mr Black says: “There is a lot of fudging, there are a lot of boxes which will be ticked but practice may be different.”