Meeting the European Working Time Directive has proved a major challenge for acute specialties in 2009. Those responsible for providing maternity, paediatrics, surgery and anaesthesia have faced particular difficulties not least because of the need to have specialty specific clinical services available 24 hours a day.
The European Working Time Directive (EWTD) has meant that since 1st August 2009 all staff in all NHS organisations - with the exception of a very small minority -
should now be working no more than 48 hours a week.
The directive is in essence health and safety legislation aimed at ensuring both the safety of patients and the safety of the NHS staff who work for those patients.
It should also, if implemented properly, serve to safeguard the quality of training and the work/life balance of junior doctors.
In January all ten Strategic Health Authorities (SHAs), the medical Royal Colleges under the Academy of Medical Colleges, the British Medical Association, NHS Employers, Skills for Health and the Department of Health joined forces to create the EWTD Reference Group. The group continues to work together to help NHS services sustain the 48 hour working time requirement post 1st August.
Sustainability is key to realising the benefits of the directive for NHS staff and David Sowden, dean director at NHS East Midlands says that although sustainability is now key it may prove difficult to deliver training.
‘Sustainability is difficult because it is tied up with junior doctors and their training and we don’t know yet whether compliant practices are delivering the right education and training for junior doctors in the learning environment in which it needs to be delivered.’
Mr Sowden believes that it is possible to deliver good training within 48 hours but warns that some trusts have taken a ‘simplistic approach’ to the directive and questions whether, as more junior doctors work out of hours, they will get the supervision they need.
It is important for trusts to recognise that the 48 hour week and the directive offer a degree of flexibility. The measurement of whether a member of staff is working more than that will be referenced over a 26 week reference period. Contracts will be drawn up requiring staff to work an average 48 hour week. Doctors who are working in an emergency situation will not be expected simply to stop work because their shift has finished - although rotas and working patterns themselves should be built so that this situation is unlikely to happen in the first place.
There are of course some derogations in 24 hour acute emergency specialities for trusts demonstrating that they are working towards the 48 hour week.
Trusts who struggled in their efforts to meet the directive may need additional support to sustain compliance and expert help can be obtained from SHAs, Skills for Health - Workforce Projects Team and the East of England’s targeted support team:
www.healthcareworkforce.nhs.uk/targetedsupportevaluation
Dr Jenny Harrop deputy director of NHS North West’s EWTD medical development team warns that NHS trusts must not take their eye off the ball. ‘In the North West we are building service rotas with trainees and are constantly checking on any problems which might be putting implementation of the directive at risk, she explains.
‘The situation will always be very fluid and there will always be the need to have someone in each region working to make sure the 48 hour week continues to be met,’ Dr Harrop adds.
Bill Dunlop, emeritus professor of obstetrics and gynaecology at Newcastle University, previously president of the Royal College of Obstetricians and Gynaecologists says that if organisations ‘properly implement’ tried and tested solutions to meeting the EWTD it can be sustained.
‘In general, trust chief executives have not been on board with implementation and many have waited until the last minute to act. I think we will have to wait and see what happens,’ he says. The Department of Health through SHAs is continuing to routinely collect monthly progress reports required to understand how NHS trusts are complying with the directive.
Mr Sowden further commented that it will be a number of months before it comes clear but the problems are in ensuring continuing EWTD compliance. He also warns that the impact of a pandemic flu outbreak is unknown in how it will affect compliance. He says that trusts will need to look at how services are provided and staffed. “Many trusts are still referring to EWTD as a target which had to be met by 1st August and board level understanding of it is at best patchy.”
Dr Diana Hamilton-Fairley, deputy medical director at London’s Guys’ and St Thomas’ Foundation Trust Hospital agrees. She says that without a full debate about the role and training of new doctors EWTD is not sustainable.
‘We need to rethink what we are training doctors for. People are scared to have that debate because it means talking about changing the nature of the consultant’s role - but I can’t see how high quality patient care and EWTD are going to be sustained otherwise.’
She believes that it will be ‘very difficult’ to sustain adherence to the EWTD in smaller district general hospitals where compliant rotas can fall down as soon as one doctor is off sick:
“I think the only way the EWTD could be sustained is to do things very differently. The NHS needs to become a lot less reliant on junior doctors for the delivery of services. We need to start looking closely at the way in which services are structured and try to deliver services with the minimum number of doctors needed at night. This will ensure that groups of patients are covered by a single doctor rather than lots of specialties working at the same time.”
At its heart EWTD is a ruling that the NHS must use to ensure patient safety remains paramount whilst ensuring the best quality training for junior doctors in the modern world.
Working Time Directive 2009 
