Commissioners and trusts should see the WTD as friend not foe

Gerry Bolger, project director WTD / Hospital at Night, London Deanery and senior project manager, Skills for Health - Workforce Projects Team, explores WTD and puts forward the case for joined up service improvement thinking.

WTD 2009 requires doctors in training to be working no more than 48 hours in a week from 1st August 2009. Fundamentally it is a safety directive and as such, is enshrined in health and safety legislation in the UK.

However implementing WTD is not as easy as just getting everyone to reduce their hours, especially when compounded by changes in service delivery, training and education of junior doctors.

WTD is now part of the NHS Operating Framework. The framework requires commissioners to ensure that WTD is part of the overarching work in provider organisations. This aside, commissioning of services is not just about numbers; quality is central to the work we are doing, and while PbR is about funding, the commissioning role is about ensuring better care and better value.

Central to this, commissioners should be looking more closely at the impact of and solutions being considered around WTD. If those solutions are new ways of working such as bringing in new and emerging roles to reduce the workload on medical staff, such solutions need to be tested under value and safety. One such solution ‘Hospital at Night’ whether in its basic form of just night time or extended to out-of-hours or advanced to a 24:7 model allows such safety initiatives to be built in while reducing hours. Using workforce teams differently means that solutions can be found which are both affordable or even cost neutral.

But WTD is not a standalone issue. Where organisations have considered its impact, they are already starting to ‘reconfigure’ workforce differently. The risk for those trusts that don't start addressing it until after they have dealt with the current hot topics such as the 18 week wait means there is a real risk of destabilising both. For example if a trust focuses on dealing with the 18 week wait by adding in extra theatre sessions, in 2009 when the requirements have to be in place, a possible loss of income and work could be experienced.

Those NHS organisations which embrace the key ‘must-do’s as well as the WTD together are likely to be winners. Trusts which leave it until after April 2009 to start the process of dealing with WTD are at best unlikely to have it planned and solutions in place and at worst at risk of destabilising key service delivery requirements such as emergency access and the 18 week wait.

Commissioners should be asking key questions such as how are your plans going to meet both the service delivery expectation and WTD requirements? What will this mean for both the medical workforce and healthcare workforce as a whole? If they are not satisfied with the answers they need to ask that further work is done.

In all of this is the need for intelligent joined up workforce planning. For some specialities, the implications could mean a 14 percent reduction in medical workforce availability, or as a minimum one doctor less per shift per week; trusts and commissioners need to start thinking wider than just medical staff. As part of overarching workforce planning the whole workforce needs to be assessed. The reason for this is that while we address one profession to meet the challenges, the impact cuts across the whole healthcare workforce, and may mean a reduction in headcount in one area but an increase in others.

With WTD there should be an impact needs assessment so that trusts can assess implications and implement sustainable solutions which are both affordable and do not compromise care. To do this, commissioners need to start asking the questions now and not in 2009.