Next month (August) the European Working Time Directive laws reduce the limit on junior doctors’ hours from the current average of 56 to 48 per week.
According to the Department of Health 48 hours is consistent with 'patient safety, high quality patient care and good work/life balance for doctors' and the Directive is supported by the BMA.
The DH is seeking 'limited derogation' for an extra four hours per week 'that could be applied in some hospital services providing 24 hour immediate care' and the EWTD can allow individuals to opt out and work up to a 56 hour week.
Here we take a look at the key dates and events in the journey of the EWTD, from its agreement by the European Commission in 1993 to its implementation in 2009, by talking to some of the key people who have had a significant impact on its implementation in the NHS.
1993 European Working Time Directive agreed.
1998 UK Working Time Regulations implemented (excluding junior doctors).
1998 Hospital at Night (HaN) concept conceived by Professor Elisabeth Paice, dean director of the London Deanery.
Professor Paice says:
'It all started with a conversation with a surgical registrar who told me his training was being affected because he was spending increasing amounts of time on call at night and was unable to take advantage of valuable daytime elective surgical and clinical opportunities.'
The concept of 'an active night team of people who would expect to be busy and not expect to sleep' was embraced by colleagues who developed and refined the HaN concept.
Professor Paice's priority was to improve the quality of training for junior doctors, within the new limits on the working week.
'One of the most important ways was by seeking the engagement of trainees themselves - hearing their voices.'
'The annual PMETB survey results identify good practice which can be shared and act as a screening of training which may need to be reviewed', she says.
Specific changes to training to ensure it can be delivered within a 48 hour week include an £11 million investment by NHS London in Simulation and Technology enhanced Learning Initiatives (STeLI), e-learning and 'train the trainers' programmes.
'We have to train differently in this new world,' says Professor Paice. 'We say that every hour at work has to carry an educational punch.
'Using simulation is training through rehearsal - our mantra is 'why practice on patients?'
'There is still a way to go before we optimise training within the shorter working week but it can be achieved.'
2000 Horizontal Amending Directive (HAD) extends EWTD to cover doctors in training;
European Court of Justice (ECJ) SiMAP ruling defines all time a doctor is required to be on hospital premises as work.
2002 DH and Modernisation Agency start EWTD 2004 programme in response to SiMAP Ruling, establishing stakeholder working and new ways of working pilots.
Candace Imison, deputy director of policy at The King's Fund and former Modernisation Agency lead for HaN, helped to take the concept forward to a piloted, evidence based solution ahead of the 2004 58 hour challenge.
'As the project moved on, it became clear that the patients were the focus. If this had purely been a technical exercise in compliance, it could not have been sustained.
'The fact that it was palpably delivering care through a system which was much better for both patients and doctors
is what led to its success. Everyone involved in HaN was totally committed.'
She says that changing the way doctors work is challenging, but creating a steering group which brought together the Royal Colleges and the BMA and chaired by Judy Hargadon, 'made a huge difference.'
'My hope now is for the ambition for Hospital at Night to be realised through Taking Care 24:7 which will be a huge step forward for the quality of patient care.'
2003 New Deal contract implemented; ECJ Jaeger judgement on compensatory rest.
2003/04 Dr Simon Eccles, then chairman of the BMA Junior Doctors Committee and former medical adviser to the DH on HaN, led the development of the programme with Candace Imison, in the light of the SiMAP ruling.
'Virtually nobody objected to the ceiling of 56 hours but the new ruling effectively prevented overnight on call,' says Dr Eccles.
More and more hospitals introduced their own 'version' of HaN, which Dr Eccles says must involve completely reorganising night staffing to maintain patient safety and maximise training.
'It is absolutely vital to have clinical leadership at a local level - within individual departments and organisations - as well as a national level. Without it, changes are bound to fail.'
He says he is 'disappointed' that some clinicians waited until the Directive was close to becoming law to express their reservations.
'Part of the solution is enhanced training for other staff to take on roles which need not be performed by doctors,' he says.
Dr Eccles says that EWTD compliance applies to individual doctors not their rotas: 'Trainees who rotate through areas like primary care and public health with low out of hours commitments, can offset those against more onerous on call situations within the rotation. The aim is to maximise learning opportunities and minimise the time wasted on basic tasks.'
2004 Rosemary Cook oversees completion of EWTD 2004 NHS pilot projects.
2004
Working Time Regulations cover doctors in training - 58 hour week and appropriate rest breaks. Skills for Health Workforce Projects Team (then National Workforce Projects) succeed NHS Modernisation Agency as lead organisation to support NHS with EWTD 2009.
The EWTD 2009 programme is led by Sue Dean, Rachael Charlton and Nigel Burgess.
2005 HaN roll out and with extension to 24:7 solutions. Gerry Bolger, programme director for Quality in Nursing for Chief Nursing Officer’s professional leadership team was the former project director who led the roll-out of HaN across England.
He says: ‘Hospital at Night involved changing the process from providing reactive services to proactive ones and the biggest challenge has been engaging with those clinicians who did not believe in the concept.’
But in late 2008 a ground breaking survey of 22 hospitals produced evidence which showed HaN was delivering improvements. Data obtained six months before and six months after the hospitals implemented HaN showed that length of stay and unnecessary transfers to others hospitals had fallen and the Standardised Mortality Ratio was reduced at most of the sites.
He says the exercise should be repeated in the future when information systems to monitor the effects of HaN, which are still being developed, will demonstrate the outcomes for patient safety.
‘HaN now has international recognition in Australia and Hong Kong and is under consideration in America - it would not have been accepted elsewhere if people did not believe in it.’
HaN was also ‘Highly Commended’ in the Patient Safety category of the 2008 HSJ Awards.
'What clinicians have to understand now is that EWTD is not optional, it is the law, designed to improve patient safety and their own safety and well being.'
2005/06 Three trusts, (Guys and St Thomas’, Liverpool and Broadgreen Hospitals and South Devon Healthcare) adopt the Taking Care 24:7 project to achieve EWTD compliance ahead of 2009. Dr Diana Hamilton-Fairley, consultant obstetrician and gynaecologist and deputy medical director at Guy’s and St Thomas’ NHS Foundation Trust, who has led on EWTD compliance since 2003:
‘I view the Directive as a challenging opportunity to improve patient care and everything we have done to achieve compliance has had patient safety at its core,’ she says. ‘We know that tired doctors are not safe for patients, for themselves or their families.
‘Patient safety has been top of the trust’s agenda for the last four years - it is what drives change and we are permanently reviewing our systems.’
Evidence shows that the trust’s Standardised Mortality Ratio has reduced substantially due both to work on EWTD compliance and a wider culture change, according to Dr Hamilton-Fairley. The number of serious clinical incidents (RED incidents) has fallen from 16 in 2003 to one in 2008 and the number of ORANGE incidents has also dropped.
She says that changes have been made trust-wide rather than department by department with vital clinical collaboration helping to find common solutions to the problems.
‘One of our secrets was achieving sign up to the key role of a consistent leader and organiser for both the clinical and managerial aspects of running the hospital,’ she says. ‘Agreement that the site nurse practitioner should be the coordinator was absolutely vital to the success of the changes.’
Dr Patrick Chu, divisional medical director for diagnostics and therapeutics and former director of education at the Royal Liverpool and Broadgreen University Hospitals NHS Trust, helped to lead the piloting and implementation of HaN.
‘Before EWTD I was aware that junior doctors’ training needed to change and we were already making headway with promoting team work,’ says Professor Chu, whose 2003 presentation to the DH illustrating the hospital’s vision was a key milestone.
‘My vision is that the person who is best able to look after a patient should be mandated to do just that, whatever their title,’ he says.
Dr Chu believes that the success of HaN is teamwork and, providing clinical governance and risk management are robust, experienced nurses are capable of aspects of care previously done by doctors.
Even before the pressures of EWTD, Dr Chu, in his former role as clinical director of haematology, included nurses in his team who were specially trained in a variety of roles previously done by doctors.
He believes the way to EWTD compliance is not automatically to employ more doctors - ‘that is expensive and unfair on career progression’ - although that may be necessary in some specialties.
‘We must use other innovative solutions, tailored to the profile of each individual hospital.’
2005/07 Professor Roy Pounder, Emeritus professor of medicine, University of London, and former vice president of the Royal College of Physicians (RCP) and EWTD lead, first considered the evidence of the effects of consecutive night shifts on doctors’ health, lifestyle and safety record. At a conference in November 2005, attended by equal numbers of junior and senior doctors and administrators, world experts, who had studied the effects of shift work on safety records, concluded that ‘sleep-deprived junior doctors have more attentional failure and make more clinical errors’.
In 2006, Professor Pounder and RCP colleague Nicholas Horrocks published a 24 page guide ‘Working the Night Shift: Preparation, Survival and Recovery’ followed by a document entitled ‘Designing Safer Rotas in the 48 hour week’.
‘It had been common for a large percentage of junior doctors to work seven consecutive night shifts which clearly involved risks to both themselves and their patients,’ says Professor Pounder. ‘After our work, the Department of Health advised that doctors should work no more than four consecutive night shifts.’
The EWTD’s requirement for 11 hours continuous rest in a 24 hour period is ‘absolutely vital’, he says. ‘It is safer for doctors and safer for patients.’
2007 Professor David Sowden is appointed as interim director of Medical Education England and strengthens collaboration between MMC and EWTD.
2007 Professor Sir John Tooke heads Aspiring to Excellence: Independent Inquiry into Modernising Medical Careers, recommending in January 2008 that a new NHS: Medical Education for England take responsibility for junior doctor training. 2007
Working Time for doctors in training reduced to 56 hours. Homerton University Hospital NHS Foundation Trust and the Wrightington, Wigan and Leigh NHS Foundation Trust are among the first to implement
2009 requirements.
John Coakley, medical director and consultant in intensive care medicine at Homerton, which used HaN as a means of achieving the first 58 hour and subsequent 56 hour week, says: ‘EWTD has been a significant driver for change and there will always be a need to reassess those changes.’
The changes were implemented through vital ‘good project management’ and a steering group which included three trust executives and junior doctor trainees.
The Homerton succeeded in meeting the new working hours - ‘in the teeth of some opposition’ - by separating emergency care from elective in service delivery and separating junior doctors’ rotas into time dedicated exclusively to emergency care and time for the development of skills in base specialties.
‘The most important aspect in redesigning service delivery is to think about how the patients go through the system - including length of stay, emergency admissions - to determine what size of wards you need, what body of clinicians.
‘You must be bold - think outside the box and consider that some changes will incur costs, others will save money. Overall we have saved money, although that was not the driver.’
Equally important is the involvement of the staff who will be affected by service delivery changes and gaining quick feedback from the junior doctors on training opportunities and rotas. ‘When we first redesigned the rotas to be compliant, they did not meet the trainees’ needs,’ he says. ‘Immediately they told us, we made changes.’
2007/08 Professor Bill Dunlop, former president of the Royal College of Obstetricians and Gynaecologists (RCOG) and chair of the BMA’s Joint Consultants Committee, champions the trained doctor/consultant based solution for the specialty. After leading a group responsible for meeting the 2004 58 hour week, Professor Dunlop was aware that some units were already achieving 48 hour compliance.
He studied the successful solutions in different hospitals to see where best practice could be shared to help to meet 2009 compliance.
‘It was clear there is no single solution - it depends on many factors including the size of the unit and the range of consultants,’ he says.
He says that while EWTD compliance may be easier to achieve in obstetrics and gynaecology than in paediatrics - in some cases by establishing midwifery led units - consultant expansion is the answer.
‘But that is the greatest challenge, not least in deciding how it can be financed,’ he says.
Professor Dunlop says there are positive benefits. ‘It is quite clear that when consultants are available, they can make different decisions which can have a positive effect on many issues, including reducing litigation.’
2008
EWTD reports published by the Royal Colleges of Surgeons, Anaesthetists, Paediatricians and Obstetricians and Gynaecologists urging the NHS to have robust implementation plans.
2008
NHS North West EWTD team win HSJ Workforce Development Award. Dr Yasmin Ahmed-Little, a member of the CMO’s clinical advisers’ scheme at NHS North West, was the former project director to the EWTD team which achieved early implementation across the North West, a role now held by Dr Deborah Kendall. She says:
‘From 2005 we started to look at radical solutions to solve the 48 hour challenge in the light of what had been done to meet the 2004 Regulations. We were clear we needed an evidence base to show the impact of any changes.’
She admits that even in 2006/07 many still felt EWTD was ‘far enough away not to worry.’
The creation of WPT, formerly NHS National Workforce Projects, offered support as the network aimed to share identified best practice.
‘We knew solutions had to be sustainable to deliver the best possible care and best possible training,’ she says.
‘From the start we involved trainees - we did not want them to feel changes were being imposed on them.
‘One difficulty is that the juniors with whom trusts have worked up to now are not the same people who will start in August.
‘If people can grab the new doctors coming to them and involve them in the new rotas and training at the start, it is a worthwhile investment. If you do not do that, it may take a long time and a lot of resources to catch up.’
Looking beyond August 2009, Dr Ahmed-Little says that trusts ‘must not be scared if everything is not in place’ providing they have interim solutions and agreement on compliance.
‘But they must ensure they have robust monitoring systems in place and be prepared to make changes if they become necessary.’
2008 Dr Michael Bannon publishes research with Sheffield University that found most junior doctors believe they are getting good quality training within an average 56 hour week.
2009 Royal Colleges, DH and NHS Employers group oversees EWTD 2009 Quality Assurance regime.
2009 The development of the consultant role in paediatrics is led by Dr David Shortland, vice president of the Royal College of Paediatrics and Child Health.
2009 MMC Working Group Report on quality of training published;
Independent evaluation of EWTD 2009 pilots published, demonstrating that EWTD compliance is challenging but achievable.
2009 (May) Conciliation talks between Council of Ministers and European Parliament to amend the EWTD, fail.
2009 (25th June) Derogation Statutory Instrument is laid in Parliament. Miss Wendy Reid, consultant in obstetrics and gynaecology at The Royal Free Hospital, London and national clinical adviser to the Department of Health for EWTD.
She says: ‘I became involved with HaN when there were gaps in the out of hours service at my hospital, which has since been developed and tweaked.
‘It is now clear that HaN is no longer a project, but part of the culture which is a measure of its success - those who have introduced it can no longer imagine life without it.
‘Hospital at Night has been developed in different ways to match local needs, led by clinicians prepared to consider working differently and not driven by a bonus for delivering it!
‘It has also become clear that the concept can be adapted to provide 24:7 care as long as organisations understand that it is a different challenge as daytime pressures are not the same as those at night.’
Miss Reid, who says her role is to reflect all sides of the EWTD debate, acknowledges that there are still anxieties around compliance, particularly among the Royal Colleges. ‘Those concerns need to be backed by evidence,’ she says.
Miss Reid says that although 1st August is a major date - the reference period for compliance is six months - the DH will continue a level of scrutiny and support beyond it.
‘We need to be scrupulously honest and acknowledge that even with an agreed plan, there may be a ‘what if?’ element at the start,’ she says. ‘Good management of human resources needs constant vigilance.
‘No one wants or deserves to be treated by tired doctors who may make mistakes. And it is not a badge of honour to work excessively long hours and ‘survive’. We have to move away from this macho, long hours culture and practise medicine with the patient at the centre of the service.’
2009 (August) Implementation date and focus on sustainability.
Working Time Directive 2009 
