European Working Time Directive and its impact on training Medical Education England Independent Enquiry Chair Professor Sir John Temple June 2009

European Working Time Directive (EWTD) Healthcare ;- is always supervised, and is usually delivered by trained doctors

What is a ‘Trained Doctor’? MB Ch B or equivalentX Membership/Fellowship of Royal CollegeX Certificate of Completion of Training -CCT

Concern about the ability of the NHS to deliver training in 48hr week Review the impact of the EWTD on the training of – Dentists – Doctors – Healthcare Scientists – Pharmacists

Time for Training A review of the impact of the European Working Time Directive on the quality of training Professor Sir John Temple

A comprehensive review process (Dec 2009 – April 2010)

Evidence v Assertion Real evidence is lacking Repeated –Assertion –Opinion or –information was taken as a proxy for evidence Trainees perceptions were very important!

EWTD impact is greatest when workload involves;- – high emergency and/or – out of hours cover

High Quality Training can be delivered in 48 hours This is precluded when: trainees have a major role in out of hours service

EWTD impact Training & service are inextricably linked 48 hrs leads to > in shift working Shifts require > doctors to maintain cover Rota gaps > frequent

Rota Gaps Loss of elective training X2 Enforced rest Generality Rota Gaps not Speciality (usually out of hours) Limited learning Poorly supervised

The effect of service on training

Just how much training is provided in the current working week in the UK? In a 7 year training programme with 48hrs/week There are 15, 000 hours potentially available

Who covers the nights?

Findings – Consultant Expansion Trainee increases have enabled retention of existing services and configurations

Findings Consultant ways of working often support traditional training models Traditional service and training models waste learning opportunities

Comparisons Population Med students Residents UK 60 m8,00050,000 Canada 30 m3,50010,000

Make every moment count -1 Training must be;- –Planned –Focused Handovers must be;- -effective -safe -supervised

Make every moment count -2 Accelerate learning by using:- –Simulation –Role play –Video consultation –Other technologies In controlled environments before practising on patients

Skills Lab

Use of simulation accelerates the acquisition of skills

Effective implementation of EWTD results in – Improved work/life balance – Enhanced supervision – Reduced loss of daytime elective training – Improved handovers This produces safer patient care

EWTD can be a catalyst for change Service reconfiguration Hospital at Night Consultant & Trainee contract flexibility Training simulation and new technologies

The case for change Reliance on trainee doctors to deliver a 24/7 service has to change Increasing – hours/length of training now will simply maintain the present system

Recommendations - 1 Implement a consultant delivered service Service delivery must explicitly support training Learning must continue to be service based Make every moment count

Consultant delivered service C T

Consultant delivered service (CDS) Readily available Graded supervision Resident CDS Only when service load demands) Viable sized teams No other duties (when on call) Service re-organisation

Consultant delivered service Lead to closer supervision by consultants; – Increase learning opportunities – Improve, diagnosis & treatment – Enhance patient safety And reduced patient costs

What is a fully Trained Doctor? Completed a training programme Certificate of Completion of Training (CCT) Appointed to a Consultant position in NHS

Consultant delivered service –Trainee programme 7yrs –Consultant 25-30yrs Consultant:trainee alignment –Consultant : Trainee 3:1

Consultant delivered service Action > Consultants < Trainees Service Teaching  Not all consultants or services will have trainees

Consultant delivered service 24 hr presence or ready availability for direct patient care More flexible working of the consultant contract Multi disciplinary Team - not ‘Firm’ approach Mentoring of all consultants

Recommendations - 2,3 & 4 Some service redesign is necessary Recognise, develop and reward training Training excellence requires regular planning and monitoring

Public Expectation Right Healthcare ;- is always supervised, and is usually delivered by trained doctors

High quality training can be delivered in 48hrs To achieve this the NHS needs: – Fundamental changes to training & service – Clear Leadership – An explicit implementation plan Action is needed now

We must produce Competent, confident and safe doctors who will embrace life long learning. ‘Training today is patient safety for the next years’

EWTD – the fine points Introduced 1998 Full implementation – 48 hrs – 1/8/09 Working time includes – on the job training on call at the workplace Junior doctors are not classed as night workers Simap & Jaegar rulings

Time for Training A review of the impact of the European Working Time Directive on the quality of training Professor Sir John Temple