European Working Time Directive and Operative exposure

Mr MS Baguneid

TreasurerAssociation of Surgeons in Training

“Changes”New Deal

Unfinished business

Modernising Medical Careers

Seamless training

CCT / “Generalists”

Independent sector treatment centres

Reconfiguration of the SAS grade

Entry into specialist register

PublicExpectations

GovernmentManifesto

EWTD

PMETB

EWTD

Nov 1993 Component of EU health and safety legislation (Directive 93/104/EC)

Oct 1998 Enacted into UK law (Doctors in training excluded)

Aug 2000 Doctors in training included (Directive 2000/34/EC)

April 2002 19 Pilot projects funded by DOH

Implementation

Aug 2004 - 58 hours

Aug 2007 - 56 hours

Aug 2009 - 48 hours

Rest Periods

11 hours' continuous rest in every 24-hour period

Minimum 20-minute break when shift exceeds 6hrs

Minimum 24-hour rest in every 7 days or Minimum 48-hour rest in every 14 days

Minimum 4 weeks' annual leave

Maximum 8 hours' work in 24 for night workers

SiMap (Oct 2000)

Doctors who are resident on-call at the hospital are deemed to be working, even if they are sleeping.

Non-resident: “work begins when disturbed from rest and ends when resumed”

The problem is huge!

Aug 2004 (58 hrs)

213,000 hrs/week lost

Equivalent to 3700 Juniors (compliant)

Aug 2009 (48 hrs)

208,296 - 476,638 hrs/week lost

Equivalent to 4,300 - 9,900 Juniors

“Inquiry into the European Working Time Directive (EWTD) -

evidence from the BMA". Feb 2004

Derogation

No derogation for overall hours limit

Derogations for rest periods

Compensatory rest

JAEGER Ruling (Sept 2003)

The Jaeger ruling on compensatory rest means that a rest period must be taken immediately after the period of work which generated it

Various strategies

1) Reducing inappropriate duties and enhancing support for appropriate ones

2) Diverting workload geographically3) Delegation of doctors workload to others?4) Generating and allocating additional

resources5) Changing working patterns6) Development of Night teams7) Expansion of numbers

Enhancing training1) Separation of service/ training2) Wet labs and skills workstations3) Virtual Reality models4) Fresh Cadaveric work / Use of animal models5) Recognition of trainers who train (Silver Scalpel

Award)6) Competence based assessment7) Use of ISTC for training (Role needs to be

clarified)8) Training lists (Cases to be tailored)

Survey (Countess of Chester)

Operative time (Trainer vs Trainee)

Inguinal hernia 45%

Varicose vein surgery 29%

Lap Cholecystecomy 38%

Carotid endarterectomy 28%

Working patterns“One size does not fit all!”Current on-call rotas are mostly non-compliant

Non-resident on-call not feasible for manyTrusts not keen to pay for “being available”Large regions make travelling difficult“Off site residence” is a legal “fudge”

Shifts are largely inevitableFull shift requires 8 – 10 middle grades ( + needs

at least 10 consultants?)

Shift work - downside

Lack of continuityLoss of operative exposure 30-50%Edinburgh SpR survey:

Over 50% considered < 72hours/ week inadequate 90% prefer to work longer week (even 90hrs)

Full shift + 48hrs = Daytime activities reduced by 79%*29.5hrs/week to 6.15hrs/week*

The European Working Time Directive – interim report and guidance from The Royal College of Surgeons of

England Working Party. Jan 2003

Operations by Trainees 1.3.2002 – 28.2.2003

Total Number of Operations = 87824Total Number of Trainees = 456

70

47

83 82

5458

35

27

0

10

20

30

40

50

60

70

80

90

1-50 51-100 101-150 151-200 201-250 251-300 301-350 351-400

Number ofTrainees

Number of Operations (in bands of 50)

Impact on training

1993 30,000 hours

2004 8000 hours

Near future 6000 hours

Genius

Improvement in quality of training

Reduced standards

US stand:

The American College of Surgeons published an official statement of its views on resident work hours (Public health law: < 80 hours/ week!)

“It is illogical to make specific time-work recommendations without considering the effect on education”

“lack of familiarity with a patient, not fatigue, is the major cause of errors of judgement”

RCSEng stand:

“very concerned that the time frame of the European Working Time Directive, as applied to doctors in training, may compromise safety of

surgical care and the training of surgeons”

Brussels/ UK Gov Stand:

Trusts which do not comply by August 2004 could be fined for non-compliance.

Fines of up to £5,000 per breach could be levied, as well as imprisonment.

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