As August 2009 approaches, the changes and challenges faced in delivering EWTD 2009 compliance have become a key clinical priority.
EWTD is essential health and safety legislation for all workers, providing subsequent benefits for those at the centre of our work and training… our patients. This is particularly important in obstetrics, where emergencies can occur at any time involving mother and baby, with frontline staff needing to maintain optimum performance at all times.
Whilst there is no single solution to achieving EWTD compliance, a full systems approach to delivering a 48 hour working week for doctors in training provides the opportunity for all areas of service and training to be reviewed, with regular revision of solutions where appropriate. The restrictions of EWTD have major implications for postgraduate trainees specialising in obstetrics and gynaecology, with a training programme which is fixed in length for a minimum of seven years.
Potential changes to promote training within the 48 hour working week include focused training lists, enabling trainees to maximise the benefits of the reduced time available. Training may become more targeted, with trainees excelling in subspecialty areas.
Alternative ways of providing service such as the Royal College of Obstetricians and Gynaecologists' call for further consultant expansion and changing work patterns may also benefit trainees, with more supervision for trainees. As consultant cover on the labour ward expands and consultant resident on call shifts are introduced, trainees may find more opportunities to train under direct consultant guidance.
Although there are several potential solutions and alterations in work patterns which have been tested by employers in the quest to achieve EWTD compliance and deliver good training, the exact combination to success may vary from trust to trust. Above all, involving junior doctors when considering changes to rotas and training arrangements is paramount, most are keen to be involved and are passionate not only about maximising training opportunities but, of course, making sure the best care possible is given to our patients.
Dr Shreelata Datta
Chair, terms and conditions of service and negotiating subcommittee
BMA junior doctors committee
JDC view on EWTD
It's almost a cliché to say that we face significant challenges to the delivery of patient care because of the Working Time Regulations (or EWTD as most people call it).
Just as significant in the long term are the challenges the EWTD poses to the quality of training. The BMA, like many trainee organisations, has been expressing concern about this for some years.
A new sense of urgency has set in across the NHS, and although many changes are too late to meet the August deadline, this does not mean that the effort should not be made to meet the limits while still training the senior medical workforce of the future to the standards we have previously demanded.
This may involve re-introducing training lists, so that the reduced time available to trainees in procedural specialties like surgery or cardiology can be spent most productively on training.
Where individual trainees are able to control their own working hours, and are not being bullied into doing so, they could opt out of the EWTD hours limits. However, EWTD being health and safety legislation, it may be better for the colleges to consider extending the indicative duration of training programmes to compensate for the reduced training time available in a compliant programme.
Alternative ways of providing service will be needed, too, and funds have been provided centrally including through a tariff uplift for EWTD solutions; consultant expansion is being strongly pushed in many specialties, particularly paediatrics and obstetrics.
Whatever changes happen in your organisation, the JDC would strongly recommend involving juniors in discussions about changes to rotas and training arrangements.
Well, he would say that, wouldn't he? - yes, but our experience time and again has been that involving the trainees avoids so many of the problems that can occur with top-down imposition of changes that miss subtle nuances of training needs and contractual issues. Juniors care about patients and about our training, and you will find us keen to help address the issues thrown up by the EWTD.
Dr Tom Dolphin
Vice chair of the BMA's junior doctors committee
EWTD 2009 at the Homerton
The European Working Time Directive 2009(EWTD) has seen many recent changes for junior doctors.
My hospital was among the first to pilot a new method of incorporating the EWTD into everyday working practice. A new Acute Care Team (ACT) was formed which aimed to have a team of medics, surgeons and intensive care doctors working alongside one another to manage all new admission as well as the very sick ward patients. I was one of the first junior doctors to start on this team.
The initial rota was not attractive making us junior doctors on the ACT rather unhappy. The number of patients requiring admission to hospital had not changed, yet the number of hours worked by doctors had. The only way around this was to calculate hours on an average with doctors working very long irregular shifts some weeks and more regular hours other weeks. After a weekend of nights we would only have one full day off and stretches of ten days in a row finishing at 10pm were not uncommon. Frustratingly, the irregularity made it difficult to follow patients fully through their hospital stay. Studying for professional exams was difficult and many doctors also felt their in-hospital training was compromised.
After much experimentation and long discussion involving decision makers and junior doctors, I am pleased to say things have now significantly improved. The team responsible for introducing the new way of incorporating the EWTD 2009 into the hospital consisted of the medical director, a number of senior staff as well as project managers, who were employed specifically for this role. They were present in many of the handover meetings from the outset and observed the running of the ACT. They made themselves available to listen to the needs of the doctors and any views on patient safety that had arisen over the initial weeks. After the first two months, a steering committee, of which I was a member, was established. The committee met regularly and addressed all issues including rota design. This helped no end. Thanks to the hard work of the hospital doctors and the willingness of the project leaders to act on feedback, the ACT now runs successfully with the EWTD perfectly incorporated into daily working life.
Dr Rosena Khan
Speciality registrar, Homerton Hospital, London
Working Time Directive 2009 
