European Working Time Directive and Operative exposure Mr MS Baguneid Treasurer Association 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 Public Expectations Government Manifesto EWTD PMETB

EWTD Nov 1993Component of EU health and safety legislation (Directive 93/104/EC) Oct 1998Enacted into UK law (Doctors in training excluded) Aug 2000 Doctors in training included (Directive 2000/34/EC) April Pilot projects funded by DOH

Implementation Aug hours Aug hours Aug 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, ,638 hrs/week lost Equivalent to 4, ,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 geographically 3)Delegation of doctors workload to others? 4)Generating and allocating additional resources 5)Changing working patterns 6)Development of Night teams 7)Expansion of numbers

Enhancing training 1)Separation of service/ training 2)Wet labs and skills workstations 3)Virtual Reality models 4)Fresh Cadaveric work / Use of animal models 5)Recognition of trainers who train (Silver Scalpel Award) 6)Competence based assessment 7)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 hernia45% Varicose vein surgery29% Lap Cholecystecomy38% 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 many Trusts not keen to pay for “being available” Large regions make travelling difficult “Off site residence” is a legal “fudge” Shifts are largely inevitable Full shift requires 8 – 10 middle grades ( + needs at least 10 consultants?)

Shift work - downside Lack of continuity Loss 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 – Total Number of Operations = Total Number of Trainees = 456 Number of Trainees Number of Operations (in bands of 50)

Impact on training ,000 hours hours Near future6000 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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