Can junior doctors' night hours be reduced without threatening their training?
Michael Read and colleagues explain how one department managed it
Reducing hours of work without decreasing training and service provision is a seemingly impossible task. We have introduced measures to reduce out-of-hours work intensity that have allowed vocational trainees to maintain their daytime training opportunities without falling foul of the New Deal or the rest of the department.
Much of the work undertaken by GP senior house officers at night can be more appropriately done by other healthcare professionals. Admissions and out-of-hours surgery can be reduced to a minimum. This allows vocational trainees to 'swap' their night hours for day hours, thereby improving the learning opportunities afforded by outpatient clinics.
Under the New Deal, hours of work should have been progressively reduced within the agreed targets by December 1996 so that no junior should be on duty for more than 72 hours a week, and no more than 56 hours should be spent working, with the rest of the time on call. But a review published in 1997 showed up to a quarter of posts had failed to meet these targets.1
This reflects the difficulty of implementing the targets. Most of the initiatives introduced to reduce hours have been designed to meet the service aspects of the trainee's work, with scant consideration of the quality of the training received.2,3
In our unit, the hours worked have been reduced in line with the New Deal for both senior house officers and registrars without resorting to partial shifts, which have been almost uniformly unpopular with obstetrics and gynaecology trainees.4 Out-of-hours work intensity has been reduced and some attempt has been made to ensure that training is appropriate for both vocational and career trainees.
Vocational trainees (doctors planning to go into general practice) and career trainees (doctors planning a hospital career) have different training requirements and should not be lumped together. In this article, SHO refers to a vocational trainee, and registrar refers to a career trainee.
There are no career trainees at SHO level in the department of obstetrics and gynaecology at Gloucestershire Royal Hospital - a situation common to most units in the UK. Only 11 per cent of obstetrics and gynaecology SHOs in the UK have declared an intention to follow a career in that specialty.5
We have introduced two quite different timetable patterns for the SHO and registrar tiers, tailored to their different requirements. It is important to keep in mind that the reductions in hours have only been achieved within an infrastructure where out-of-hours work intensity is reduced to a minimum.
Both the Royal College of Obstetricians and Gynaecologists and the Royal College of General Practitioners have agreed that training in obstetrics is too hospital-oriented, particularly with the move towards more community- based care in line with the recommendations from the Department of Health's expert group on maternity care.
The progressive reduction of junior doctors' hours has reduced training opportunities. Any on-call night duty is 'compensated' with time off. This has meant a reduction in the '9 to 5' training of SHOs with a consequent reduction in outpatient clinics, perhaps the most pertinent parts of training.
We have solved this by reducing the after-hours commitment of vocational trainees in order to increase their exposure to appropriate daytime training opportunities while remaining within the New Deal recommended hours.
The SHOs work a 54-hour week. They work a standard 40-hour week with one in four on call until 10pm Monday to Friday, and every fourth weekend they work Saturday and Sunday 9am to 9pm. Incorporated into this working week is one half-day session for study and one further half day to attend a community antenatal clinic.
The role of the SHO in obstetrics has been discussed at length. One study concluded that normal labour should be managed by midwives and a registrar involved only where problems arise.6
Much of the out-of-hours workload of obstetrics and gynaecology SHOs is not appropriate to their future work.
It is difficult to see the relevance for most SHOs of learning how to do practical procedures on the labour ward as only a minority of GPs will be directly involved in the management of labour in their subsequent careers.
We asked our SHOs to keep a diary of their on-call work for one month. In addition, a consultant acted as the SHO on call for several nights to test the appropriateness of the work.
Many of these tasks were considered either inappropriate to SHO training, or more appropriately performed by other healthcare professionals, or resulted in unnecessary duplication in that the registrar would almost invariably be involved as well.
The registrars work a 64-hour week. We have four middle-grade doctors and one senior registrar who covers the senior SHO, unless someone is away, when they work a 'registrar' night.
The main out-of-hours duties recorded in obstetrics were: establishing intravenous infusions, interpreting heart rate traces, attending assisted deliveries and assisting in central delivery suite theatre. In gynaecology they were: emergency admissions, and assisting in theatre.
The registrars work a fixed day and night (24 hours) of the week with a day off afterwards, and they have Monday off after a weekend on call. This complies with the New Deal recommendation of, 'at least eight hours' rest during a period of duty. Most of this should be continuous if possible.'
In addition to the day off, one week in four there is also a half day for study/special interest and a further half day for the departmental education programme, providing the registrars are not covering the central delivery suite.
One common criticism levelled at this system is that it is difficult to protect educational sessions such as theatre lists. This has been overcome by altering the consultant timetables - the consultants agreed to conduct their peripheral clinics single-handedly on the day after the fixed day on call.
It is of paramount importance that any reduction in the SHOs' hours of duty does not increase the registrars' workload. To this end we have introduced a number of initiatives to reduce the quantity of out-of-hours work and the number of inappropriate tasks undertaken.
Extending the role of nurse practitioners/midwives to help share the workload has been advocated for many years. Our department has made it possible with several training programmes.
Midwives have taken a lead role in suturing episiotomies and perineal lacerations as part of their extended role for a number of years. If a perineal laceration requires medical attention, it is appropriate for a registrar to attend and, if necessary, repair the tear.
We identified a number of midwives who wished to develop their skills to include assisting in theatre and in caeserean sections, and training is provided, thus obviating the need for an SHO to be resident on call 'just in case' they were needed.
The concentration of emergency referrals is a cornerstone of the system. The introduction of early pregnancy assessment clinics and a gynaecology review clinic have been important in reducing admissions. The early pregnancy assessment clinic, open seven days a week, allows investigation of women with pain or bleeding in early pregnancy who might otherwise have to be admitted.
Allowing women with miscarriage a choice of how they are managed has reduced the number of evacuations of retained products of conception procedures by 40 per cent with no reported difference in patient satisfaction, success and complication rates.
Local GPs suggested that a daytime, open-access review clinic in gynaecology would reduce emergency admissions. In response, the gynaecological review clinic was introduced in July 1993, and referrals for any suspected acute gynaecological pathology, except early pregnancy, are made through the on-call registrar.
One in seven women referred have subsequently been admitted. But after the clinic was established there was a 25 per cent reduction in the number of emergency admissions. A review of the remaining emergency admissions revealed that up to 65 per cent of these could have been seen in the review clinic. With optimal use of the clinic there could be a 70 per cent reduction in the number of emergency admissions.
Extending all elective operating lists by up to one hour has allowed the great majority of the 'emergencies' to be accommodated. This also provides consultant cover for the juniors, a mutually convenient solution that can only improve patient care and juniors' training.
In the first six months after the introduction of the above measures, 17 gynaecological procedures were performed out of hours - less than one procedure per week. This includes any procedure being performed after the end of the afternoon operating list or at any time during the weekend, and represents a reduction of 91 per cent compared with the 1992 figures. After the introduction of the review clinic there were only 45 emergency admissions after 9pm in six months. This represents one admission every four days.
To assess the effects of the changes we undertook an anonymous survey of all 50 members of the department - SHOs, registrars, midwives and gynaecology ward/theatre staff - followed by a series of focus groups.
The results showed midwives on the central delivery suite felt most affected by the changes. But most conceded that the changes had a potentially positive effect on midwifery practice development, provided there was adequate training. The registrars felt largely unaffected by the changes. The SHOs wanted protected central delivery suite time and opportunities to gain experience of obstetric complications during their on-call day. There was also a feeling that their skills were perhaps under-utilised and there was potential for improvement in 'sub-specialty' GP skills such as hormone replacement therapy clinics.
It would be inappropriate to suggest that all these measures could be imported wholesale into every obstetrics and gynaecology department. But departments could tailor at least some of the principles to suit their own requirements.