Posts Tagged ‘WTD’

Campbell needed to raise EWTD’s profile

By Stephen Campion - 6th August 2010 2:14 pm

My days of having to take holidays when the children are not at school are, thankfully, long over. But the lure of a few days away from the office and attending a number of courses (some with more attractive 19th holes than others) got the better of me. When I got back I switched on the TV News and was arrested by this headline “Campbell Court Case drama!”

“What on earth has Alastair been up to now?” I wondered, whilst at the same time angry with myself for possibly missing a high profile political drama. Then I realised it was not the model of spin in the dock, but Naomi. Apparently she went to bed after dinner with Nelson Mandela and was woken up in the early morning by two men knocking at her hotel bedroom door who thrust a pouch of dirty stones into her hands. Nice work if you can get it. Those stones turned out to be diamonds; but who cares? I would willingly have volunteered to be the delivery boy - and would certainly have done the gentlemanly thing and washed the stones first.

Still upset that Alastair had not made prime-time viewing I suddenly felt a twinge of sympathy for Mr John Black, the president of the Royal College of Surgeons. He managed to raise the stakes in the increasingly bitter and divisive arguments over the infamous Working Time Directive. His survey shows what many medical practitioners and commentators have been saying for some time - training is being diluted, and patient care put at risk, as a result of well-meaning but poorly executed legislation.

Why the sympathy? If Naomi can overcome Alastair to be the top news story, what chance has Sir John got? It is clearly not the importance of the story that captures prime-time news but the celebrity involved. Now, if Sir John really wants to apply news pressure on the Working Time Directive I would suggest we team up to knock on Naomi’s door.

Even if we make no progress it would liven up the news!

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Working Time Directive is “spectacular failure”

By Mike Broad - 1st August 2010 9:19 pm

Surgeons’ representatives have called the working time directive “a spectacular failure” following new research suggesting care has deteriorated since its introduction a year ago.

Eighty per cent of consultant surgeons and 66% of trainees say that patient care has deteriorated under the working time directive.

The Royal College of Surgeons, Association of Surgeons in Training and British Orthopaedic Trainees Association are all campaigning for a 65-hour week, which they believe offers the best balance between adequate training opportunities, good patient care and work-life balance.

The survey’s results - taken from 980 surgeons covering all nine surgical specialties in England as well as those based in Scotland, Northern Ireland and Wales - compare unfavourably to a similar research undertaken last year.

Sixty five per cent say their training time has decreased - a quarter more than in October 2009.

More than a quarter of senior surgeons are no longer able to be involved in all of the key stages of a patients’ care, compared to 18% in 2009.

Two thirds of trainees have reported a decline in training time in the operating theatre and 61% of consultants report that they are operating without trainee assistance more frequently since the directive was introduced in August 2009.

Forty one per cent of consultants and 37% of trainees reported ‘inadequate handovers’.

This follows Hospital Dr research which showed that shift working and multiple handovers top the list of problems doctors face in delivering good care.

Almost three quarters of trainees and two thirds of consultants are consistently working more than the permitted hours. Over half of trainees say they cover rota gaps which result in them working in excess of their contracted hours, compared to 44% in 2009.

One consultant surgeon, who responded to the survey, said: “The European Working Time Directive has been a training disaster. We are raising a generation of demotivated, demoralised and poorly trained surgeons. The UK will pay for this and regret it for at least 30 years.”

Mr John Black, president of the Royal College of Surgeons, said: “To say the European Working Time Regulations has failed spectacularly would be a massive understatement. Despite previous denial by the Department of Health that there was a problem, surgeons at all levels are telling us that not only is patient safety worse than it was before the directive, but their work and home lives are poorer for it.

“The new government have indicated they share our concerns, but there is not a moment to lose in implementing a better system which would enable surgeons to work in teams, with fewer handovers and with the backup of senior colleagues.”

Mr Charlie Giddings, president of the Association of Surgeons in Training, said: “The survey shows that 12 months after the full implementation of the WTD there has been little progress with improvements to quality of training or to the quality of life of trainees and the subsequent impact on patient safety.

“New innovative solutions are required rather than the minor short-term tweaks that artificially produce compliance at the expense of training and patient care, which trusts have attempted so far.”

A spokesman for the Department of Health said: “The health secretary will support the business secretary in taking a robust approach to future negotiations on the revision of the European Working Time Directive, including maintenance of the opt-out.

“We will not go back to the past with tired doctors working excessive hours, but the way the directive now applies is clearly unsatisfactory and is causing great problems for health services across Europe.”

Meanwhile, additional RCS research suggests that the proportion of NHS patients having to wait longer than the 18-week target for non-emergency surgery had almost doubled from 1.5% 18 months ago to nearly 3% in March 2010. It blames the WTD.

Commenting on the findings, Royal College of Physicians president Sir Richard Thompson said: “We are not providing the service or the training that we require. I cannot over-emphasise the damage to service provision and to training.”

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Shift handovers are a barrier to good care

By Mike Broad - 22nd July 2010 8:21 am

Shift working tops the list of problems hospital doctors encounter in delivering good patient care, a Hospitaldr.co.uk survey reveals.

78% of the 409 respondents believe that miscommunication during multiple shift handovers is causing difficulties, and the overwhelming majority felt that better structured handovers and smoother shift transitions would improve care.

The survey - by GS1 UK and Hospitaldr.co.uk - reveals that 54% of hospital doctors believe that removing the 48-hour week would help.

Other barriers to good care include nursing shortages (according to 70% of the doctors who responded), a target driven culture (74%) and inadequately trained staff (61%).

In a damning indictment, only 7% of doctors believe that revalidation would improve patient safety in their hospital.

The survey suggests that technological advance could play an important role in making doctors more efficient. 35% of hospital doctors say they’re unable to locate key patient information at least once a day. And 12% feel they rarely have enough time to check patients’ medical records thoroughly before treating them.

When asked about which technological innovations would be of the greatest benefit in helping them perform their roles more effectively, the top three suggestions from hospital doctors were: access to real-time electronic patient records; access to real-time views of stock levels of medical supplies and medicine; and bar-coded wrist bands to accurately identify patients and provide essential care records.

Real-time electronic patient records were cited by 78% of doctors as a development which would help them perform more effectively.

Gary Lynch, chief executive of GS1 UK, said: “As the new government defines its policy for health service provision, some of the key priorities relate to increasing efficiency and shifting towards measuring the outcome of a patient’s treatment rather than the number of cases handled.

“The feedback from hospital doctors is that patient care would improve and medical staff would be able to work more efficiently with greater access and sharing of information electronically.”

Read a blog on the survey.

Results at-a-glance:

Which of the following do you think are responsible for causing problems with patient care?

Miscommunication in multiple shift handovers 78%

Target driven culture 74%

Nursing shortages 70%

Staff not having enough time to thoroughly check patient records before assessing patients 61%

Inadequately trained or experienced clinical staff 61%

Reliance on locums 54%

Shortage of equipment or supplies 26%

What do you think would most contribute to improving patient safety in your hospital?

Better structured handovers 69%

Less targets 61%

Removal of 48-hour working week restrictions 54%

Increased middle and senior grade cover out-of-hours 52%

A unified, multidisciplinary patient record 49%

Improved reporting of clinical errors 45%

Revalidation 7%

More targets 1%

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It’s not all about the big picture

By Mike Broad - 21st July 2010 10:48 pm

The government wants the NHS to do more with less (or, if a member of the media is within earshot, to do more with about the same). To achieve this, if indeed it is achievable, everyone is going to have to work a lot smarter.

And so we’ve got the White Paper, which shakes up primary care and once again seeks to usher in the private sector in pursuit of competition and efficiency.

But, efficiency isn’t just about the big stuff. Torching all the SHAs, PCTs and quangos before lunch and then shooting a few managers in the afternoon might grab the headlines but large scale re-organisations are often slow, expensive and rarely deliver the intended results.

Real progress - in both efficiency and quality - will be found in improved working practices and how services are organised locally. And that’s why we surveyed hospital doctors on how things could be improved.

Shift handovers are clearly a serious problem. If we don’t have the balls to modify the working time regulations, then trusts have got to adopt best practice and bring uniformity to the process.

It’s all very well for Sir John Temple to say every handover should be a well-planned and supervised learning opportunity (hang on a minute, when was the last time you attended a post-take ward round Sir John?) but the reality for many consultants is very different.

It’s also concerning that, according to hospital doctors, a lack of staffing and training resources are already compromising care. This is only going to get worse. At least the government appears to be tackling targets, another highlighted problem.

Our survey also offers some clear pointers for IT development. Time is regularly wasted finding medical records. Clinicians want to be able to access real-time electronic patient records.

How much public money has been spent on the NHS IT programme and yet we still can’t deliver this? It’s starting to make the Millennium Dome look like a successful project.

The message is a difficult one for a government with no money to stomach: you’re going to have to invest a bit more before you can make long-term savings. Having said that, scrapping the 48-hour week wouldn’t cost a penny…

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Temple’s recommendations on medical training under the WTD

By Mike Broad - 23rd June 2010 2:29 pm

The Working Time Directive was fully implemented into the NHS in August 2009.

Widespread concern has emerged about the ability of the NHS to continue to deliver safe services and high quality training for all its staff.

The traditional experiential model of training in England relied on trainees spending long hours in their place of work delivering services, during which time they developed their skills and knowledge. Given the reduction in the time available necessitated by the WTD, the challenge now is to continue to deliver high quality training within the current service context.

The government requested that Medical Education England commission an independent review of the impact of the WTD on medical training.

The ensuing review, chaired by Sir John Temple, released its findings earlier this month; it acknowledged that a 48-hour week is compromising medical training but suggested the solution lies in developing a truly consultant-delivered service rather than extending the working week for juniors.

Key findings

1. Gaps in rotas result in lost training opportunities.

2. WTD impact is greatest in specialties with high emergency and/or out-of-hours commitments.

3. Consultant ways of working often support traditional training models.

4. WTD can be a catalyst to reconfigure or redesign service and training.

Key recommendations

1. Implement a consultant delivered service:

The review emphasises the need for a ‘consultant-delivered service’, rather than the more loosely defined ‘consultant-based’ or ‘consultant-led service’ to become a reality. A consultant delivered service is defined as consultant 24-hour presence, or ready availability, for direct patient care responsibility.

Consultants may be the most costly members of the workforce but they make better decisions more quickly and are critical to reducing the costs of patient care while maintaining quality. A consultant delivered service should be seen as part of the solution to funding pressures.

A consultant delivered service will necessitate more flexible consultant working and will require, in many cases, reconfiguration or redesign of the way that services are currently delivered. Where clinical need dictates, this may involve 24/7 consultant working involving shifts.

There needs to be further development of the consultant role: concepts such as team job planning and the pooling of PAs and SPAs among a team of consultants will enable flexibility within a team. Newly appointed consultants need mentoring and support.

Trainees will still provide services - they should not be supernumerary. Delivering direct patient care is an important part of training in both elective and emergency situations. With increased consultant presence out-of-hours, trainees will gain from the experience of working under supervision.

2. Service delivery must explicitly support training:

Services must be designed and configured to deliver high quality patient care and training in order to deliver safe and effective healthcare in a consultant delivered model.

Regional or national reconfiguration solutions may be required for smaller specialties.

Reconfiguration and redesign of elective and emergency services can benefit training and patient care.

MDT working must be used to support training. Working efficiently in reduced hours will require a co-ordinated multidisciplinary approach of the relevant professions to ensure suitable alignment of roles and utilisation of their available skills, coupled with interdisciplinary learning. There must be a national strategy with clarity on the service responsibilities and cost efficiencies for the development of roles such as physician assistants, specialist nurses, advanced nurse practitioners and surgical care assistants, as these professionals can reduce unnecessary demands on junior trainees.

Service requirements and training quality may mean that it is no longer feasible to train in all hospitals.

Rotas require organisation and effective management. General recommendations include: formalising a collaborative approach to rota design by actively involving trainees; an educational supervisor or person with responsibility and understanding of trainee education should assess and sign off the overall educational value offered in a rota; use appropriate, available software tools to assist with the design of busy, complex rotas; and, enable trainees to have some flexibility when planning annual and study leave.

There must also be a reappraisal of current employment contracts for doctors to better support training.

3. Make every moment count:

Training must be planned, focused and individualised. There needs to be an increased awareness by trainers and trainees of the learning opportunities in each and every clinical setting and training must be targeted and well planned in the 48-hour week.

Handovers must be effective, safe and supervised and represent an opportunity for learning. There must be improved mentorship and support of trainees.

We must accelerate learning by using simulation and technology in a safe, controlled environment.

Sir John says we must implement better ways of training, combining current best practice and innovation. Many consultant trainers’ perceptions are aligned to traditional models of training that they experienced, which involved long hours, personal sacrifices and less formalised support and supervision.

To meet the challenges of the developing environment an alteration is now required in the way training is delivered.

4. Recognise, reward and develop trainers:

Consultant educators need to be identified, trained, accredited and supported in their job plans, through mechanisms similar to those that currently exist for GP educators.

There should be flexibility for consultants to be training or non-training. The principles of the model used in general practice, in which not all principals are trainers and the trainer and trainee roles are clearly defined, should be adapted for hospital practice.

Training must be recognised in consultant job plans. Trainers must be developed, supported and accredited learning new approaches to medical education. Trainer excellence must be recognised and rewarded.

5. Training excellence requires regular training and planning, and commissioners’ levers should be strengthened to incentivise training.

6. Prioritise training at trust level:

The quality of training must be monitored. The absence of definitive evidence on the impact of the outputs and outcomes of training highlights the need for a rational, realistic system for monitoring the effects of reduced working hours, and other system changes. This must result in actions being taken where deficiencies are found.

Read the full review.

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“48-hour week is compromising O&G training”

By Mike Broad - 12:09 am

Nine out of ten O&G trainees have had to cover daytime rota gaps since the Working Time Directive was introduced, a survey reveals.

The rise in unfilled posts, following the implementation of a 48-hour week, also resulted in 49% of trainees covering gaps during evenings and weekends and 36% at night.

Over 950 trainees responded to the Royal College of Obstetricians and Gynaecologists’ survey.

It also reveals that 16% of trainees believe their rotas were not WTD compliant at the time of the survey, and nearly all blamed insufficient staff numbers.

Nearly a third of O&G trainees felt that there had been an overall decrease in training sessions.

Respondents felt that achieving competence and the confidence to do independent 2nd on-call duties may be an issue at ST2/3 levels. More alarmingly, those on sub-specialty and advanced training felt that obstetric on-call cover impacted negatively on their training. ST5 trainees feel less confident to do independent out-of-hours acute gynaecology.

Dr Maggie Blott, the college’s vice president (education) said: “The results of this survey will help us to focus on the weak areas in specialty training. It has raised issues which we are particularly concerned about, such as the knowledge gaps and the lack of opportunities to train, which this survey has identified.

“What we need to remember is that O&G is a high-intensity discipline and long shifts where trainees have little rest will compromise safety. We must strike a balance between what trainees can achieve within the confines of a normal working day with the demands of work. We will work with the trainees and trusts to ensure that our trainees receive adequate training and don’t burn-out at the same time.”

On the positive side, trainees mentioned that it was because of the WTD that supervision by senior staff has improved. And it had also resulted in greater consultant presence in the labour ward.

The government-commissioned Temple review recently acknowledged that the WTD had damaged training but suggested the solution lay in truly consultant-delivered services rather than an extension to the 48-hour week for trainees.

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“Political will exists to extend 48-hour week”

By Mike Broad - 17th June 2010 9:48 am

The president of the Royal College of Surgeons says there is now the “political will” to tackle the 48-hour week and its damaging effects on training.

Mr John Black said, in the college bulletin, that he had recently spoken to the new health secretary Andrew Lansley and suggested he was sympathetic to the college’s campaign against the WTD.

He said: “The Secretary of State for Health assured me that he has given sorting out the problems produced by the EWTR a very high priority. He is well aware of the current crisis it has produced in the NHS, with deteriorating patient care and seriously compromised training. He knows the massive cost to the NHS, with in one trust 15% of the medical staff budget going to pay for locums for rota gaps that would not exist with a sensible hours regime.

“I told him that there could be no better way for the new government to get surgeons (and I suspect many other doctors working in acute care) on their side than to remove the restrictions of the EWTR.”

Last week, the Temple review acknowledged there are problems with access to training but suggested they would not be eased by either increasing trainees’ work hours beyond 48 hours nor lengthening training programmes.

Instead, the review suggested that rota gaps can only be overcome with a fundamental change in the way training and services are delivered. It says that, despite a 60% increase in consultant numbers over the past 10 years, hospitals remain reliant on juniors to provide out-of-hours services.

Chair Sir John Temple recommended a move to a consultant delivered service, with seniors more directly responsible for the delivery of 24/7 care.

Black said the health secretary has several options to lengthen juniors’ training “including UK primary legislation, a formal sector opt-out within the current European law or a modification to the EU Social Chapter”.

He continued: “The new foreign secretary, William Hague, has indicated publicly that the EU should not set junior doctors’ hours of work. As I have said throughout what is needed is political will and this is now there.”

He said: “The key, given removal of the legal restrictions, is a contract for junior surgeons based on training, with hours worked becoming secondary. Proper hands-on training should become a contractual commitment from employer to trainee. Properly drafted new rules would stipulate team working (the old firm structure), which would restore continuity of care to patients.

“We look forward to working with Mr Lansley to achieve this and it is very good news that he understands the urgency. There are many difficulties to overcome but at last we are moving in the right direction.”

Earlier this year a BMA survey claimed that half of juniors were missing out on training opportunities following WTD implementation.

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“Consultants must work more flexibly”

By Mike Broad - 9th June 2010 1:22 pm

Consultants hold the key to solving juniors’ lack of access to training following the implementation of the European Working Time Directive, a government-commissioned review finds.

The review, chaired by Prof Sir John Temple, acknowledges there are problems but suggests that they will not be eased by either increasing trainees’ work hours beyond 48 hours nor lengthening training programmes.

Instead, the Temple review suggests that rota gaps can only be overcome with a fundamental change in the way training and services are delivered. It says that, despite a 60% increase in consultant numbers over the past 10 years, hospitals remain reliant on juniors to provide out-of-hours services.

Sir John recommends a move to a consultant delivered service, with seniors more directly responsible for the delivery of 24/7 care.  

Training should continue to be delivered in a service environment, says the review, called Time for Training, with appropriate consultant supervision. But, consultants should be prepared to work more flexibly and place a higher priority on training juniors.

It says some specialties, such as obstetrics and paediatrics, have already moved to more flexible consultant working, allowing trainees to gain experience under supervision.

Sir John said: “I recognise that the WTD may be reviewed in due course. However, the transformation of training needed now is paramount and must be addressed regardless of any modifications in order to produce well-trained professionals for the future.

“Training is patient safety for the next 30 years.”

The Temple review says trainers and trainees must use the learning opportunities of every clinical situation, with handovers being an effective learning experience when supervised by consultants.

Services must be designed and configured to deliver both high quality patient care and training. It suggests that reconfiguration of elective and emergency services, and an effective Hospital at Night programme, are two ways to support training. And rotas require organisation and effective management to maximise training opportunities. 

However, the Temple review warns that as the ratio of trainees to consultants changes with increasing consultant numbers, it may no longer be feasible to train in all hospitals.

Dr Shree Datta, chair of the BMA’s junior doctors committee, commented: “The report makes it clear that high quality training can be delivered within the constraints of the 48-hour working week, however, this is dependant on implementing the recommendations in full. It cannot simply be put on a shelf to gather dust.

“It is also essential that there is an emphasis on resolving the problems faced by doctors working in specialties where the impact of the WTD on training is most severe. Seeking the input of those worst affected, such as surgical trainees, will be key in improving the opportunities for training at work.”

Earlier this year a BMA survey claimed that half of juniors were missing out on training opportunities following WTD implementation.

Mr John Black, president of the Royal College of Surgeons, said: “We are relieved that this report openly acknowledges that the WTD has critically damaged medical training in the UK. However, we are deeply disappointed that the remedies proposed are unworkable. It is unrealistic to put training concerns above those of patients and there are not the bottomless resources available to fund these proposals. The one obvious solution for the acute specialties - that of removing the WTD itself - is not assessed at all.”The Temple review recommends that consultants, in substantive roles, should remain clinically responsible for service delivery and training. “An expansion of any other grade will not support the move to a consultant-delivered service model,” it says.

 

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“Training is now under threat on many fronts”

By Mike Broad - 10th May 2010 8:46 am

The incoming government has to prioritise medical training and safeguard the quality of the NHS medical workforce, delegates heard at the BMA’s annual junior doctors conference.

Dr Shree Datta, chair of the BMA’s junior doctors committee, said research shows that four in 10 juniors are working on understaffed rotas, and that they are increasingly working more anti-social hours in which training opportunities are scarce.

She said: “The NHS prides itself, quite rightly, on its highly trained staff, but the quality of doctors it produces depends on the quality of training provided. Alarmingly, our training is now under threat on many fronts. By the £20bn worth of efficiency savings; by the understaffed rotas one in four of us now have to work on; by a haphazard review of training funding and by the fractured implementation of the 48 hour week.”

Datta added that BMA research revealed that nearly half of doctors are also missing out on essential training.

She said: “Working extra shifts to prop up understaffed rotas means less time to learn new procedures, less time to practice our skills, less time to learn and less time to become better doctors. Without proper training junior doctors will not be able to gather the skills, experience and knowledge needed to be the GPs and consultants of tomorrow.”

She also warned that the next government needs to improve workforce planning to ensure doctors are properly equipped to meet future demands.

“There is a clear and urgent need to review the medical workforce so that the number of medical graduates closely matches the number of specialty training places and the need for consultant and GP posts.

“If junior doctors do not have a realistic chance of becoming a consultant or GP - we risk wasting precious NHS funding and creating a generation of frustrated underemployed doctors.”

Read her full speech.

 

 

 

 

 

 

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Juniors look after up to 400 patients at night

By Mike Broad - 21st April 2010 1:19 pm

There are large variations in the provision of medical cover at night following the introduction of the Working Time Directive, with some doctors being responsible for up to 400 patients, a study finds.

The research, by the Royal College of Physicians, reveals that doctors were responsible for an average of 61 patients at night but the range was from 1 to 400.

The seniority of doctor in charge of a ward also varied considerably; 63 teams reported that, on the night the survey was carried out, the most senior medical cover was a junior doctor in their first two years of training. Consultants were involved in the direct delivery of overnight care in only 6% of teams.

Day cover on the ward ranged between two and 65 patients per junior doctor, with the highest ratio per doctor in Wales and the lowest in London. This reflects a much higher number of trainees in the capital (in 2008 there were 1,135 specialist training posts in London compared with 146 in Wales). The average number of patients per doctor also varied considerably between specialties.

Dr Andrew Goddard, director of RCP’s medical workforce unit, said: “The very low number of doctors per patient at night in some hospitals raises serious concerns for patient safety and there are also worrying reports of very junior doctors being left unsupported, which urgently require further investigation.”

The survey - sent to consultant physicians in England and Wales on a specific date in November - also raises concerns about junior doctors’ welfare. Fifty eight percent of consultants reported an increase in sickness rates of juniors working under them compared with before the introduction of WTD-compliant rotas.

The survey claims to be the first to get independent evidence of current sickness rates for junior doctors across England and Wales, and shows that they are higher than a recent survey by the NHS Information Centre suggests.

The study proposes that high sickness rates in second year trainees may reflect a loss of team working and sense of belonging in doctors a year into their training.

It also shows a vacancy rate of 8.6% among specialist trainees.

Goddard said: “The 48-hour week was brought in to improve the wellbeing of doctors, and by extension prevent mistakes in patient care. The apparent rise in sickness rates of junior doctors since the introduction of the European Working Time Directive highlights the additional stresses that are being put upon trainees by new rotas.

“Far from benefiting their welfare, the poor implementation of the directive means that juniors are missing out on crucial support and valuable training opportunities, and patient care is being spread too thinly.”

On the day of the survey, data was available on 887 hospital teams at 11am, including 4,004 junior doctors caring for 18,854 medical patients, and on 670 teams at 11pm, including 2,263 junior doctors caring for 97,561 medical patients.

 

 

 

 

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