Effects of the European Working Time Directive on anaesthetic training in the United Kingdom
Summary
Decreases in the hours worked by trainee anaesthetists are being brought about by both the New Deal for Trainees and the European Working Time Directive. Anticipated improvements in health and safety achieved by a decrease in hours will be at the expense of training time if the amount of night-time work remains constant. This audit examined the effects of a change from a partial to a full shift system on a cohort of trainee anaesthetists working in a large district general hospital in the South-west of England. Logbook and list analyses were performed for two 10-week periods: one before and one after the decrease in hours. An 18% decrease in the number of cases done and an 11% decrease in the number of weekly training lists were found for specialist registrars. A 22% decrease in the number of cases done and a 14% decrease in the number of weekly training lists were found for senior house officers. Furthermore, a decrease of one service list per specialist registrar per week was seen, which will have implications for consultant manpower requirements.
The New Deal for trainee doctors and the progressive implementation of the European Working Time Directive both aim to improve working conditions and safety [1,2]. The traditional on-call system meant that a night on call was preceded and followed by a normal working day. Increasing workloads made long work periods more onerous, and the New Deal attempted to match the working intensity of a post with maximum continuous duty hours while addressing rest requirements during a shift. Financial penalties in the form of high pay awards for ‘non-compliant’ working patterns [3] have lead to changes in working arrangements and, during the past three years, the introduction of shorter duration partial-shift or full-shift working patterns has affected many trainees. From August 2004, the maximum number of hours of work per week for trainees will be limited to 56 h by the New Deal.
The European Commission's European Working Time Directive (EWTD) aims to protect the health and safety of workers. A staged introduction for trainee doctors was agreed and from August 2004 their average working week must not exceed 58 h. This will undergo further decreases to 56 h in August 2007 and 48 h by August 2009 [4]. The original intention of the European Commission was that working time would not include time spent resting or sleeping at the hospital, but the Sindicato de Médicos de Asistencia Pública (SIMAP) ruling by the European Court in October 2002 meant that time spent resting in the hospital will be counted as working time from August 2004 [5]. The conclusions of the consideration of this case were supported by the ‘Jaeger’ case [6]. Therefore, total time spent in the hospital may not exceed 58 h per week on average from August 2004. This means that many current working patterns will exceed the 58 h weekly limit even though they provide rest periods that comply with the New Deal.
In order to maintain out-of-hours cover in specialties where on-site residence is required, while also complying with the EWTD, resident on-call rotas will no longer be practical. Resident trainees will do full shift rotas with a maximum duty period of 13 h. An inevitable decrease in daytime hours spent in hospital will occur, with an impact on training and service provision across many specialties.
The Royal College of Anaesthetists recommends that trainees are attached to a minimum of three consultant-theatre lists per week [7]. Minimum case numbers for some anaesthetic specialties are suggested in training documentation [8]. We audited the effects of changes in the rota from a partial-shift to a full-shift system on hours worked and both case and teaching list numbers over two 10-week periods surveyed before and after the rota change.
Methods
For the first part of the audit, information on case numbers was obtained from the logbooks of four specialist registrars (SpRs) and five senior house officers (SHOs) who were present in the hospital before and after the change in rotas and who were neither in their first three months of training nor attached to the Intensive Care Unit. Two 10-week periods, one before and one after the rota change were studied (1 August 2002–2 October 2002 and 2 January 2003–5 March 2003).
Information was obtained from departmental records of weekly solo and accompanied lists for 13 full time SpRs and 12 SHOs over the two study periods. Mean weekly list numbers per trainee were calculated. Weeks of annual leave were not counted in the calculations. The work performed by trainees attached to the Intensive Care Unit or cardiothoracic and obstetric training modules were not assessed, as the trainees are always supervised in these activities. Research, administration sessions and departmental meetings were also excluded. By studying all the full-time trainees, the likely effects on the proportions of solo and accompanied list numbers due to different training modules were minimised.
Theatre activity figures for the two periods were compared to ensure that any change was not linked to a global change in the number of cases performed in the hospital. Departmental hours records were used to calculate working hours both before and after the change.
Results
The median [range] number of cases performed by the four SpRs in a 10-week period was 102 [50–179] before the decrease in hours and was 85 [51–135] after the decrease in hours (Table 1). The decrease in the mean number of cases performed by the SpRs was 18%. The median [range] number of cases performed by the five SHOs was 119 [95–141] before the decrease in hours and was 96 [63–109] afterwards. The decrease in the number of cases performed each week by the SHOs was 22%. The mean number of weekly training lists decreased by 11% for SpRs and by 14% for SHOs. The mean number of weekly solo lists decreased by 45% for SpRs and by 32% for SHOs. Taking training and solo lists together, SpRs did an average of 25% fewer lists per week and SHOs did an average of 17% fewer lists per week.
| Specialist Registrars (n = 13) | Senior House Officers (n = 12) | |
|---|---|---|
| Weekly training lists before decrease in hours | 3.4 (3.3) [1.9–4.3] | 4.4 (4.2) [2.4–6.7] |
| Weekly training lists after decrease in hours | 3.0 (2.9) [1.6–5.4] | 3.8 (3.3) [2.3–8.0] |
| Weekly solo lists before decrease in hours | 2.3 (2.5) [0.9–3.3] | 0.9 (1.0) [0–2.1] |
| Weekly solo lists after decrease in hours | 1.3 (1.4) [0–2.1] | 0.6 (0.7) [0–1.0] |
Overall theatre activity data for the two periods were 1816 elective cases and 1402 emergency cases in the first period, and 1873 elective and 1417 emergency cases in the second period. Departmental hours monitoring data before and after the rota changes showed that the average weekly work period for a full-time trainee before the change was 48.5 h and after the change was 43 h.
Discussion
Assuming that the amount of out-of-hours cover provided by trainees and the number of trainees remain constant, the decrease in hours worked must be at the expense of daytime experience. Under the current system, the majority of teaching occurs during daytime hours. The Royal College of Anaesthetists has recommended a minimum of three training lists per week per trainee [7], and this criterion is currently being fulfilled in our department. However, our figures show a significant decrease in the number of weekly training lists after the change in working patterns. Estimates of the decrease in training hours are as high as 79% in the case of trainee surgeons [9].
Although trainee assessment is now largely based on ‘competency’, there is still a requirement for a minimum number of cases to be performed in anaesthetic subspecialty training. Where assessment of training competence includes an element of case or procedure counting, this would translate into a proportionate increase in training time to gain the equivalent experience – from 6 years to 8.5 years in the case of one estimate for surgical training [9]. In our audit, case numbers decreased by about 20% for trainees. It is possible that some of the decrease in case numbers could have been accounted for by changes in training modules and in logbook analysis, as it was apparent that an increased proportion of neurosurgical, cardiothoracic and obstetric cases occurred in the period after the decrease in hours when compared to the period before. However, the combined decrease in total list numbers was about 20% for both SpRs and SHOs, and this would tend to support a real decrease in case numbers, since overall on-call commitments did not increase after the change in working hours.
When considering training, allowance should be made for the fact that altered consultant-working patterns have meant that more emergency theatre sessions conducted out-of-hours may be consultant-lead. These lists obviously provide good training opportunities that will become more important as trainees' working patterns change. This audit considered only formal daytime training lists and did not take account of other activities such as research, administration and meetings that all form important elements of anaesthetic training.
In other countries where decreased working hours are already in place, e.g. Australia, New Zealand, Denmark and the Netherlands, training apparently takes place satisfactorily within shift systems [10]. In those countries, there is a higher doctor-to-patient ratio than in the UK, and patient care is more often consultant-delivered.
Our audit showed that solo lists undertaken by SpRs decreased by 45% after the introduction of new working patterns, i.e. about one list per week per SpR. This decrease in service provision would have implications for consultant staffing levels, particularly in departments with a heavy reliance on trainees, where the decrease in solo lists undertaken would presumably also be higher.
Good handovers can minimise the impact of shift systems on the continuity of care, and the benefit is that care is provided by staff, who are fresh rather than those who are tired at the end of a long on-call period. Good evidence exists to show the effects of fatigue on performance at work [11,12]. Good record keeping can minimise continuity problems. In smaller hospitals, staffing levels may preclude the provision of continuous cover in all specialties. Some areas may have to rationalise the provision of 24-h care between different specialties or hospitals by concentrating out-of-hours services between fewer on-call staff or by maintaining emergency cover at fewer sites [1]. This would result in increased travelling distances for patients, which might have adverse effects in emergency situations. Furthermore, this would be a politically unpopular option given the Government's commitment to the local provision of NHS services.
Shift systems have proved unpopular with many trainees because of a decrease in quality of life associated with night work and the disruptive effect on home life of spending a smaller part of more days and evenings at work. A survey of anaesthetic trainees found that shifts were thought to be poor for both quality of life and training [13]. According to the Department of Health document Guidance on Working Patterns for Doctors, a good working pattern ‘delivers training, meets service needs and WTD hours and rest requirements whilst allowing trainees a satisfactory quality of life’[14]. Employment regulations require flexible working for employees with a young family [15]. This might be difficult to accommodate in a full shift pattern.
Reallocation of duties to other staff, either by providing the same amount of night work with fewer people where cross-cover is applicable or by reallocating inappropriate duties to alternative (appropriately trained) staff groups may be possible [16]. The problem with the former is that where the intensity of work has already been found to be high, a decrease in the level of staffing may not be safe, as excessive workloads may also compromise patient care [14]. Training alternative groups to perform tasks will obviously take time, which will depend on the nature and complexity of the tasks chosen.
The Hospital at Night project aims to redefine how medical cover is provided during out-of-hours periods. The need for skilled senior anaesthetic staff throughout the night is apparent [17], and it is recognised that anaesthesia has less to gain than other specialties by reorganisation of nighttime working teams. Greater involvement of consultants in out-of-hours work is suggested, as well as further separation of emergency and elective work. The timing of out-of-hours work has been considered by the National Confidential Enquiry into Perioperative Deaths (NCEPOD) [18, 19]. Undertaking more unscheduled work during daytime hours where clinically appropriate could increase training opportunities and improve patient care. Increased out-of-hours cover provided by consultants is a possibility, but may be difficult given current levels of staffing and the recognition by the new consultant contract that normal working hours are 7.00 am to 7.00 pm Monday to Friday [20]. Night cover provided by consultants would be to the detriment of daytime operating lists. Increasing the number of trainees by increasing training numbers is neither a quick solution nor a likely one given current under-recruitment in anaesthesia. Recruitment from abroad could be implemented sooner but relies on trained doctors being poached from other countries. Expansion of the Non-Consultant Career Grade to fill gaps is not seen as a desirable long-term solution by the Royal College of Anaesthetists and would also take time to achieve. The use of non-medical anaesthetists is currently being piloted in a limited number of sites in the UK. Any impact that this might have on service provision remains to be seen, and this again would not be a short-term solution.
Trainees of the future will inevitably have a smaller volume of clinical experience to rely upon. This must be compensated for by improvements in the quality of training. Although this department could achieve EWTD compliance with minor changes to the current working pattern, other departments that have a relatively smaller number of trainees and currently rely on on-call rotas may struggle to provide both out-of-hours cover and training from August 2004.
Acknowledgement
The authors thank Dr Jeremy Langton, Consultant Anaesthetist, Derriford Hospital, Plymouth for his help in preparing the manuscript.
