Not enough hours in the week

THERE is a pattern to NHS staff reforms. They cause varying degrees of disruption, and in their wake, reports point out the changes were not properly planned or costed. This is true of the new consultants' contract, the new GP contract and last year's overhaul of the way junior doctors are trained to become specialists, which was a disaster despite repeated assurances that it would run smoothly.

The NHS is on the cusp of another reform. Next August is the deadline for hospitals cutting the working hours of junior doctors to meet the 48-hour week limit in the European Working Time Directive (EWTD).

This could mean three 10-hour shifts and two nine-hour shifts, with 20 minutes' break per day. The timetable for meeting the limit was agreed in 2000.

However, with little more than a year to go, a request under the Freedom of Information Act, sent to all mainland health boards by The Herald, has revealed that half of Scotland's junior doctors work to rotas that would breach the rule. In some health boards, more than 70% of junior staff routinely work longer hours.

Only one health board could provide an action plan for complying with the legislation and not one could project the cost.

Traditionally, hospitals have relied heavily on junior doctors to deliver frontline care, particularly at night, and the EWTD has often been referred to by NHS managers to justify the centralisation of hospital services on fewer sites.

Concentrating more juniors in one place means they can share the night work and what may be presented as an organisational issue can have a very direct impact on patients. The British Medical Association's latest guide to juniors on the subject says: "EWTD will mean there are fewer junior doctor hours available - something will have to give."

Junior doctors in Scotland should not be working more than 56 hours per week, the limit agreed by the government and medical bodies in 1991.

Alan Grant, who is training to become a general surgeon in the north of Scotland, said complying with the 56-hour target had always been quite difficult.

He said he was glad not to face the long on-call shifts and 100-hour weeks that used to be expected of young doctors, but he added: "Reducing it to a 48-hour working week really does seem to be going a little too far. You still have a commitment to provide cover 24/7. That number of hours with the number of junior doctors we have - those numbers just do not add up."

Mr Grant said he and his colleagues were also concerned about missing practical experience with the cut in hours.

"A profession like surgery is still best learned as an apprenticeship," he said. "There are some things that can be taught in a different manner, going on courses and reading books, but with surgery sometimes the only way to learn something is to be there and see it and do it. If you are not in a hospital, you will not get the exposure to do that."

Mr Grant said the time junior doctors spend training to become consultants had been shortened after the Calman report. He said: "Clearly having worked fewer hours and perhaps spent fewer years training than colleagues that came through before us, we will have less experience. You do not really want to be seeing something as a consultant, not really knowing what you are looking at because you have not seen it before."

Mr Grant's concerns are shared by others. In the British Medical Journal last week, Dr Hugh Cairns, a consultant at King's College Hospital in London, and colleagues, said the Government must relax the EWTD or it could spell disaster for the UK's medical reputation by taking doctors away from direct patient care.

Dr Alan Robertson, chairman of the British Medical Association's Scottish junior doctors' committee, said he wants the certificates showing a junior doctor has completed training to mean just as much in the future as today, but this should not be at the expense of the 48-hour week, stating: "It if means you need a bit longer to do the training, then so be it."

DIRECTIVE ACTION

The European Working Time Directive was designed to protect the health and safety of workers by restricting the number of hours an individual can work and imposing minimum rest requirements.

It became part of British law and applicable to most employees including hospital consultants on October 1, 1998.

It was agreed the EWTD for junior doctors would be implemented gradually, with the limitation of 48 hours finally being introduced in August 2009.

An interim 58-hour week applied from August 2004, falling to 56 in August 2007.

The New Deal for junior doctors, agreed between the government, the medical royal colleges and the British Medical Association, specified a 56-hour week ahead of this timetable.

As well as limiting the number of working hours in the week, the EWTD also consists of a number of rest requirements. These include: a minimum of 11 hours' continuous rest in every 24-hour period; a minimum rest break of 20 minutes after every six hours worked; a minimum period of 24 hours' continuous rest in each seven-day period (or 48 hours in a 14-day period); a minimum of four weeks' paid annual leave.

Employees can opt out, although the British Medical Association says that this is not straightforward for junior doctors because they work in teams on a rota.

A number of different authorities are responsible for enforcement, including the Health and Safety Executive which can fine organisations who breach the rules. In the past, the BMA has said it will support over-worked doctors who take legal action.