Managing Education Mr David Wilkinson Postgraduate Dean

Current work Beyond transition, the role of the PGD GMC review Budgets, do more with less Alternative workforce solutions Trainer accreditation Oriel implementation EWTD

Working Time Directive – a brief history The New Deal 1991 (Junior doctors contract) – Agreement reached in 1991 between Government, the NHS and BMA – Implemented a maximum 56 hours of work and gave definitions on ‘actual work’ and ‘rest’ European Working Time Directive (EWTD) – Became part of British law in 1998 (enshrined in European and UK law) – EWTD states that employees should not work more than 48 hours a week, averaged over a 6 month period – Staged implementation, by August 2011 all rotas had to comply with a 48 hour working week – Under EWTD any employee can choose to opt out of the limits – voluntary decision

Working Time Directive – a brief history (2) Time for Training, Professor Sir John Temple 2010 – The Secretary of State commissioned this review following concerns raised about the potential impact of the 48 hour week on the quality of training – A number of recommendations were made including implementing a consultant delivered service, service delivery explicitly supporting training and ensuring that trainees make every moment count The General Medical Council’s view – In 2012 the GMC commissioned research to assess the impact of EWTD and efforts to comply with it on medical education and training – The GMC proposed to coordinate work on rota design with partners and explore the desirability and feasibility of developing joint advice for trainees on the EWTD, and what they can expect of rotas and work practices

Legal cases SIMAP Sindicato de Medicos de Asistencia Publica (SiMAP) v Conselleria de Sanidad y Consumo de la Generalidad Valenciana (European Court of Justice, 3 October 2000) – Case brought by SIMAP, a union representing Spanish doctors – The court ruling clarified the meaning of working time within European law and means that all hours that are spent resident on-call will be counted as work no matter if the doctor is resting Jaeger Case C-151/02 Landeshauptstadt Kiel v Norbert Jaeger 2003 – This case also concerned the definition of doctors working time – The court held that the directive must be interpreted as meaning that on-call duty performed by a doctor where he/she is required to be present in the hospital must be regarded as working time in its totality, even if at rest

Banding costs The new banded pay system for junior doctors was introduced in December 2000 The aim was to secure fairer out of hours pay and to give trusts the incentive to reduce the number of hours junior doctors were working Band 3 (100%) penalty pay rates proved a lever for trusts to take New Deal issues seriously By August 2009 all doctors must have been working no more than 48 hours a week – which means all posts are in Band 1

Better Training Better Care pilots (BTBC) 16 BTBC pilots across England Developed to implement the recommendations from Professor Temple’s report Evaluation results are showing that putting structure and systems in place for medical education provides improvements to the delivery of training and patient care Plans to share the learning across the UK

Taskforce

Areas the taskforce identified The taskforce identified the following key points: – The WTD has indeed caused greater problems for some specialties than others – Local trusts have had mixed success in finding ways to manage rotas so as to mitigate the directive’s impact – If best practice were to be spread it would to some extent mitigate the WTD’s impact on the NHS – The place of service and education in contractual arrangements is important

Areas the taskforce identified (2) – Training and education in some acute specialties has proved difficult to implement with the constraints of the directive – The individual opt out for the UK as a whole is a very positive measure – The impact of court judgements following the original WTD has been substantial – It is possible that in the future the WTD could be revised in Europe to address this lack of flexibility

6 recommendations from the report The NHS should review best practice in the design of working practices, and share examples of the successful delivery of patient care and the training of junior doctors The findings of the report will need to be taken into account in the on-going contractual negotiations The specific challenges faced by some specialties should be addressed in further work

6 recommendations from the report (2) More consideration should be given to encourage wider use of the right for individual doctors to opt out of the current restricted hours The possibility of creating protected education and training time for junior doctors should be explored The lack of flexibility brought about by the court judgements is tackled, whilst ensuring doctors don’t suffer fatigue

The Government formally responded to the taskforce's report on 22 July 2014 The Government accepted all of the reviews recommendations and has committed to explore all options including; – Identifying training time that is not working time – Raise awareness of the voluntary opt-out – Review working patterns and rotas Secretary of State for Health Jeremy Hunt said “We share the longstanding concerns about the impact of the implementation of the WTD on patient care and doctors training…we will now look at how training and working time could be separately identified so we can give doctors the flexibility they need.” Government’s response to the report

Next steps Following from the Governments response the Secretary of State for Health has asked Health Education England to set up a working group to explore the options available We are leading the “Working Group to consider the recommendations of the European Working Time Directive Taskforce.” – first meeting in December

What is the problem? Full shifts!!! On call rotas less of an issue Non-operative poorly supervised activity Core / GS / increasingly T&O Log book experience poor particularly in early years Continuity, hand over, patient safety Poor feedback from Foundation doctors “It’s not like it used to be”

What is the problem? Full shifts!!! On call rotas less of an issue Non-operative poorly supervised activity Core / GS / increasingly T&O Log book experience poor particularly in early years Continuity, hand over, patient safety Poor feedback from Foundation doctors “It’s not like it used to be”

A range of views BMA – “After a year of talks with NHS employers the Junior Doctors contract negotiation stalled on 16 October after it became clear that the Government were not willing to consider a range of proposals from the BMA” The Association of Anaesthetists – Working hours should not be extended. “We strongly believe that we should steer away from a path that may return us to older educational models in which training was achieved through a process of diffusion during unnecessarily lengthy hours spent at work”

A range of views (2) Royal College of Surgeons – “relying on the opt out is not sufficient to tackle the problems the directive is causing in the NHS” “The possibility of creating education and training time should be explored” Royal College of Physicians – the widespread use of opt out should be encouraged and said “this could be done through collective agreements” Royal College of Radiologists – made recommendations for “informal arrangements where trainees are welcome to stay and learn even if the WTD deems them not able to work”.

A range of views (3) NHS employers – the complex network of New Deal hours restrictions should be removed, as this led to inflexibility of working patterns – the new contract should be consistent with the WTR, with a maximum of 48 hours work – this contract should reference the right of individuals to opt out of the WTR average hours limit – a limit of 72 hours in any single week, as well as limits on consecutive long days (10-13 hours) and on consecutive night shifts, should be introduced to ensure staff and patient safety – contractual rest breaks should be in line with those for other NHS staff. “ With this increased flexibility we believe that, as per the Temple report, training should be deliverable within the 48 hour average”

Potential solutions Separating training and education within a greater number of hours (?48 service ?8 training) Reviewing use of opting out Better use of training hours Modular training Quality of handover

Potential solutions (2) Redesign of acute services – Tiers of cover – Activity Reconfiguration of acute services – The future of the DGH – Emergency surgery outcomes

Potential solutions (3) “Shape of Surgery” – College concerned about early years training – Core / Foundation (reducing) similar experience – Wasted early years with insufficient operating

Questions?