Three specialties tell us how EWTD is working out for them.
EWTD and Anaesthetic trainees
The European Working Time Directive (EWTD) 2009 poses particular challenges for anaesthesia as a specialty.
The nature of work carried out by anaesthetists in training encompasses: the provision of anaesthesia and analgesia in the operating department; emergency work throughout the hospital, as a member of emergency response teams and in the A&E department; provision of analgesia and anaesthesia in maternity units; care of critically ill patients on the intensive care unit; and the provision of pain management services. The requirement for service provision in these fields around the clock, poses a particular threat to training for anaesthetists, as training is currently best achieved by working with consultant colleagues during 'normal' working hours.
Recommendations for optimising training within the confines of a 48 hour working week, whilst ensuring patient safety and maintaining service provision, fall into three broad categories.
Firstly, when designing and implementing rotas which are compliant with the EWTD, it is important to ensure that there are sufficient numbers of doctors on middle grade rotas to provide trainees with adequate opportunity to be trained by consultants during normal working hours. Careful and innovative rota design is essential, with as much emphasis on the requirement for adequate training as on compliance with the EWTD: 48 hours per week spent predominantly providing service out of hours would be disastrous for training.
Secondly, an increase in consultant numbers and possibly changes to both consultant and trainees’ working patterns would help to ensure that when trainees are not on call, their learning is optimised, by working with consultant colleagues as often as is appropriate to their stage of training.
Finally, the use of novel training methods such as simulation, may help to supplement clinical experience for trainees in an environment where their exposure to large numbers of cases will be reduced compared with the past.
In summary, whilst quantitively, in terms of clinical exposure and logbook case numbers, training may suffer, efforts must be directed towards ensuring that the quality of training delivered is maintained and improved.
Dr SR Moonesinghe
Elected trainee member,
Royal College of Anaesthetists’ College Council
Developments
in Paediatrics
Workforce Projects Team has developed a child health section of the healthcare workforce portal.
It sits alongside the Working Time Directive area of the site, and highlights the issues of developing an integrated workforce plan to meet the aims of the new Department of Health (DH) child health strategy paper 'Healthy lives, brighter futures - The strategy for children and young people's health'.
Healthcare organisations will need to ensure that they have the right flexible, affordable workforce to meet the needs of the future provision of childcare. In addition there will need to be demonstrable links across all the different agencies involved in child development to avoid individual organisations working in silos.
There is an agreed statement of intent on the healthcare workforce portal that recognises the issues within the current paediatric rotas and sets out the steps which key stakeholders, including the Royal College of Paediatrics and Child Health (RCPCH), the DH, Skills for Health, and the Workforce Review Team, are taking to assist organisations.
The agreed intent of the statement is that "All partners are committed to providing a service to children and their families that is top class, safe, accessible and appropriate to their needs." The statement goes on to say that "all partners including the Royal College of Paediatrics and Child Health, the Department of Health, Skills for Health, and the Workforce Review Team have agreed to work in partnership. This includes commissioning further work to ensure sustainable high quality patient services and workforce and to disseminate best practice across the NHS."
One element of this work is a study undertaken by the RCPCH into the role of the consultant. The study titled "RCPCH guidance on the role of the consultant paediatrician in providing acute care in the hospital" is currently in development and aims to disseminate information on new and innovative approaches to the role of the acute paediatrician in order to promote safe and sustainable services that meet the requirements of the 2009 European Working Time Directive. It is intended to inform the process of business planning for new posts utilising the new funds for consultant expansion in 2009, and to enable commissioners to work with paediatricians to allocate posts appropriately. While this initiative is currently for paediatric services in England only, the principles in this document are intended to apply to all four countries of the United Kingdom. The guidance document will be launched in the near future on both the RCPCH website and the healthcare workforce portal www.healthcareworkforce.nhs.uk
Bryan Kessie
Programme lead, National Priorities
Skills for Health - Workforce Projects Team
Working Time Solutions
for Obstetrics and Gynaecology
Implementation of the EWTD 2009 will present particular challenges for healthcare staff providing maternity services.
Doctors with specialised skills need to be available throughout 24 hours in order to manage the unique and urgent problems that may affect pregnancy and childbirth. These skills have been carefully defined and were first presented in a publication by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2004. Gynaecological problems on the other hand, may often be managed by stabilising the patient’s condition, using generic skills, and then calling for specialist help. While it may therefore be possible to involve hospital wide procedures (such as Hospital at Night (HaN)) to cover gynaecological problems, this is not an option for maternity care. Furthermore, since most units provide the same specialist cover for both specialties, there is a risk that the use of non specialist teams to cover gynaecology will result in reduced support for the resident, usually middle grade, obstetrician.
How can these problems be overcome? To answer this question, the RCOG undertook an exercise jointly with the Royal College of Paediatrics and Child Health (RCPCH) with support from Skills for Health - Workforce Projects Team (WPT). The objectives of the exercise, among others, were:
To obtain information from maternity units on their progress towards meeting the requirements of EWTD
To assess the impact upon training and professional development
To evaluate the effectiveness of possible staffing models.
The main findings were:
EWTD compliance was inadequately monitored in almost all units
Solutions had to be tailored to the specific requirements of each unit
Good solutions achieved a satisfactory balance between compliance and other characteristics such as patient safety, training, work/life issues, finance and sustainability
Those units with good solutions for patient safety and postgraduate training tended to have greater numbers of consultants
The needs and appraisal of trainees could be met with careful organisation but this required formal contractual recognition of time for clinical tutors
Rotas involving seven consecutive nights on call or thirteen consecutive hours per shift were inflexible and potentially dangerous. Handover arrangements required particular attention
The use of other professionals, especially midwives, to substitute for the work of junior obstetricians was of limited relevance because of staff shortages and difficulties of recruitment and retention
Service reconfigurations were already being undertaken by a number of units. However, these required considerable time to plan, meticulous consultation with other disciplines and with the public and detailed financial analysis.
The project resulted in the development of a methodology for evaluating EWTD solutions which may be of value to those units which have not yet finalised their plans for achieving compliance. Advice about funding to support implementation of the EWTD for doctors in training is available from the Department of Health website in the Children, Families and Maternity ebulletin, May 2008, Edition 38, Gateway reference 9855.
www.dh.gov.uk
Professor William Dunlop
Chairman of the Project Steering Group
Working Time Directive 2009 
