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.
I am just about at the half way mark through my consultant career, having reached my half century eighteen months ago. I spent 12 years as a junior in the NHS, one year abroad and one year taking exams, between jobs etc. Of those 12 years, 4 were spent on a 1:2 rota (104 hours per week, on-call at 35% of basic pay), 4 years on a 1:3 rota with internal cover (84 hours per week) and 4 years on a 1:4 rota (72 hours per week, but on-call now at 50% of basic pay). I now discover that having worked my rocks off as a junior and been residident in crummy accommodation most cockroaches would turn their noses up at in order to give my bosses a comfortable life, I am now expected to work my rocks off at all hours to give my juniors a comfortable life. Truly my generation is the ‘double whammy’ one, shafted at both ends of our careers!
The worst aspect is that those who have come up with these ideas will get first class medical care because my generation of highly experienced doctors will deliver it. When my turn comes, what will the quality of the next generation of consultants be like after years of non-experience under the EWTD?
Sir John is wrong.
The wish to provide excellence in training is entirely worthy but the numbers - in the current, tangled, system do not add up. The consequence is the gap in service provision that is present in most departments, most trusts at different times around the country.
Consultant flexibility in most departments is simply not an issue. Quite the reverse - it is often complete inflexibility from trainees that causes havoc. The shroud of EWTR is oft waved with consequences for both service and training.
Medical training is an apprenticeship. Experience - supervised AND unsupervised - is a key part of deep learning. Reduced hours reduces experience. Increased supervision means fewer hours for the consultant/senior supervisors to manage service delivery. At this time of recession no FT has the money or inclination to establish a consultant delivered service. Something will have to give - which services will have to go in order to deliver what are recognised as “core” services?
Oh dear!
It all sounds so sensible, doesn’t it. Trainees need lots of rest with EWHD and there training is suffering as a consequence. Answer - get the Consultants to do more of the service work and do more training into the bargain.
Has it not dawned on Sir Temple that most Consultants already work well beyond their paid hours continuing to provide the kind of service that they learnt about as apprentices in the traditional NHS. In addition, there are not nearly enough Consultants to provide the type of service he describes. We’re all on our knees trying to keep the NHS afloat while politicians fanny around with the latest initiatives.
We regularly have trainee surgeons visit us from all over the world and they cannot understand what we are doing with hours and training in the UK. They are generally much better trained than their UK peers because they spend long hours in their Hospitals. Surgery in particular cannot be taught from a book, you have to see a lot and do a lot before your become competent. I do look want to grow old in the UK….