Meeting the Working Time Directive (WTD) 48 hour requirement is a major challenge for acute specialties in 2009.
Those responsible for providing maternity services, paediatric care, surgery and anaesthesia face particular challenges, not least because of the need to have specialty specific clinical services available 24 hours a day.
The Royal College of Obstetricians and Gynaecologists (RCOG) with the Royal College of Paediatrics and Child Health (RCPCH), have been working jointly on a project evaluating the impact of implementing WTD 2009 requirements on maternity and children’s services, and exploring possible solutions. The Royal College of Surgeons of England (RCS) with the Royal College of Anaesthetists (RCOA) are working jointly on a similar project focusing on surgery and anaesthesia.
The RCOG and RCPCH have completed their project and a report, Children’s and Maternity Services in 2009: Working Time Solutions, has recently been published. The project generated a range of outcomes.
A survey was undertaken as part of the project.
The results of the survey showed that good progress has been made in WTD compliance for junior doctor rotas
(tier 1), with 67% compliance in obstetrics and gynaecology and 68% in paediatrics. There was a concern that some units may not yet be fully prepared to implement their strategies to make them compliant in 2009, however it also showed that the majority of the units that were compliant had chosen to increase medical staff and redesign rotas.
A lack of money was the most commonly reported barrier to becoming compliant as well as staff resistance to change. The colleges were keen to assess six different factors influencing and affecting WTD compliance, these were:
Patient safety
Training
Work/life balance
Finance
Sustainability
Compliance.
Professor William Dunlop, RCOG’s clinical lead for the project, said: “We found that those who had achieved compliance had used a range of different solutions which often involved using transferable skills but that was often a double edged sword, as it was difficult to do and meant that real planning had to be done.”
Although the government has allocated funding to the tune of £110m to acute specialties to help them become compliant, the money has been channelled through primary care trusts. Professor Dunlop believes that unless units and trusts are very proactive the money will ‘fall through the gaps’, he said: “The money is there but units need to make sure they get it, we are giving advice on how to do this as well.”
The project has enabled the Royal Colleges to build up a complete picture of what is happening in each unit across the country. As such they have also been able to assess the impact of the models used to meet compliance on training and professional development. They have also been able to evaluate safety, costs and effectiveness of possible models of staffing whereby clinical services can be maintained in compliance in large, small and geographically isolated areas.
The project found that the interim arrangements introduced in 2004 to meet WTD legislation will be a problem compounded by WTD 2009 because of the increased cost, reduced training opportunities and inadequate ratio of training grade posts to career grade posts.
Professor Dunlop said: “A lot of people said that finance would be the biggest stumbling block to becoming compliant but that said it is possible if it is properly factored into business plans, however there is still a worrying lack of planning on this.”
Ultimately, the RCPCH and the RCOG found that there was no uniform solution or specific combination of solutions which would enable every unit to achieve WTD compliance. The report’s findings do however show that compliance is achievable, and put forward a range of solutions that can be applied.
The RCS and RCOA joint project is still ongoing. The Royal Colleges have completed a similar survey to establish the current status for units in becoming WTD compliant by next year. Like the RCPCH and RCOG, achieving WTD 2009 compliance in surgery and anaesthetics is particularly challenging. In undertaking the survey the colleges have identified a cross section of units in size and specialties that are either making good progress towards achieving compliance or who are displaying signs of difficulty. They have also identified aspects of staffing, training and service delivery in these units in order to ascertain obstacles to achieving compliance and good practice. The project is set to finish in November when the Colleges will produce their findings and suggest possible solutions. Dr Anne Thornberry, RCOA clinical lead for the project, said:
“I am not convinced that compliance will be achieved next year, it is typical in that we play ostrich until the last minute, a lot of the solutions we have found will take several years to put in place.
“We need team working and support, doctors and other medical staff in units really need to work together, there is also a big fear that because there will be so much work for consultants to do, trainees will not want to do it.”
The project has identified what Dr Thornberry calls ‘pockets of good practice’, but she warns that there is likely to be a lot of panic towards the end of 2009 when organisations realise that they are nowhere near compliant, she said: “We will be promoting the recommendations we reach very heavily in order to help units meet this legislation, especially in terms of ensuring quality of training and patient safety.”
Professor Mike Horrocks, RCS clinical project lead agrees, he said: “We have been extremely slow to recognise the problem bearing in mind we are only a year away, what we are looking to find are trends and concepts for people to adapt rather than create off the shelf solutions.”
www.healthcareworkforce.nhs.uk/specialties
Working Time Directive 2009 
