Time to change
Authors: Lynn Eaton
Publication date: 23 Jun 2010
Lynn Eaton looks at the Temple review and what it will mean for junior doctors’ training
European legislation limiting a junior doctor’s working time to 48 hours on average a week is the reason why doctors can’t fit in sufficient training hours, many doctors would argue.
But it’s the way the NHS operates, not the European Working Time Directive, that’s the crux of the problem, argues Professor John Temple, author of a report published this month that tries to unpick the thorny problem of how to meet doctors’ training needs within a shorter working week.
Professor Temple’s report, Time for Training, was commissioned by the outgoing Labour government to look at the impact of the 48 hour limit, introduced for junior doctors on 1 August 2009 (box). But the report is now being presented to a new, coalition government. And therein lies the rub.
Key points of the Temple review at a glance
Doctors can be trained adequately within the 48 hour week (which represents a total of 15 000 hours)
Trainees are still providing too much NHS care, despite a growth in the number of consultants
Consultants should deliver more care, leaving junior doctors time to train
Annual job plans need to be introduced for consultants setting out how much time should be spent on training
Filling rota gaps with trainees does not provide them with training opportunities
Redesigning elective and emergency service cover, or developing a “hospital at night” model, can reduce the rota difficulties
Extending the hours junior doctors work or the length of their training are not viable options
Temple argues that what’s needed are more consultants delivering care, more doctors in larger rotas, and greater acceptance of training from others in a multidisciplinary healthcare team—proposals that are not new, nor particularly palatable in some circles.
But he argues that the European Working Time Directive is the catalyst that might finally make change happen. “We’ve been waiting for a consultant delivered service for at least 10 years,” he says. “It hasn’t actually happened as much as it should.”
Having more consultants in the team will, he argues in his report, mean better clinical decision making, quicker decisions about whether investigative tests are necessary, and, in many cases, fewer decisions to admit a patient in the first place. All of which will save the hospital money—even if it needs to pay more for the doctor in the first place.
Crucially, NHS Employers is one body that is prepared to buy that argument. Bill McMillan, its head of medical pay and workforce, acknowledges the Temple report could present problems, but believes it could achieve the necessary change through better use of existing consultants rather than necessarily employing more of them.
“There are roughly three consultants to every 1.6 trainees,” he says. “It’s about using them more effectively. We will get quicker, better, and sharper decisions as a result.”
There has been massive growth in the number of consultants in England’s NHS since 1999—up 62%, he says. The number of trainees has also expanded enormously in that period, up 60%. But alongside that, everyone knows that there will be cuts on the horizon in the medical school intake.
McMillan is keen to promote the idea of a job plan for consultants—an annual review of their goals for the year ahead, including their commitment to training junior doctors.
And Temple’s idea of larger groups of people working within a rota, either by combining doctors across a group of hospitals or by having some clinicians who have the appropriate skills work across more than one specialty, is something he also welcomes.
Temple is not one to mince his words. His report steers well clear of introducing a sub-consultant grade, an idea mooted some years back. Going down that road again would, Temple says, “be a disaster for the NHS,” arguing it would demoralise doctors and have an adverse effect on recruitment.
“I’ve thought about it but I’ve given up on that idea. There are some battles you will never win. We’d be removing the birthright of some 15 000 doctors if we did it.”
Learning by watching and then practising what you’ve seen takes time, he realises. And doctors don’t just learn from other doctors. He knows it is often an experienced nurse who’ll guide a junior doctor when things don’t go to plan. When he was a trainee, a nurse in the operating theatre had to show him how to suture because the surgeon in charge had—after initially training him in the operation—left the theatre.
But the training provided by nursing and other staff could be more formalised, he believes. “In psychiatry the person who first sees the patient at admission may often be a nurse. But then the patient is referred straight on to a consultant. The nurse needs to make sure the junior doctor has seen the problem early on as well.”
Although there is a role for locums and associate specialists in helping meet gaps in service provision, many locums are just papering over the cracks in the rotas, which isn’t good. Many are moonlighting, he says, by working in a neighbouring trust, which could breach European Union legislation.
“The only way to deal with this is to employ enough doctors at the right level and to look at a service redesign,” he argues.
One of his more controversial proposals is that specialists with similar core experience—say, in different medical specialties—could, within reason, provide cover for the same rota, even if it was not necessarily their specialty.
“What we don’t want developing is a situation where a clinical radiologist is asked to plug a gap in a medical rota,” he says, alluding to one case that came to light during the investigation.
Mark Porter, chairman of the BMA’s Consultants Committee, has welcomed the proposal for a shift to a consultant delivered service. “The BMA has long advocated a service organised in this way,” he says. “The challenge now is to work towards it in a systematic fashion instead of the current piecemeal approach, investing in consultant expertise to deliver high quality care.”
Meanwhile the chair of the BMA’s Junior Doctors Committee, Shree Datta, argues that the report “cannot simply be put on a shelf to gather dust, and to do so would not be in the interests of junior doctors or our patients.”
Even the president of the Royal College of Physicians, Ian Gilmore, was in favour of the change, candidly telling the Daily Telegraph: “I think part of the problem is the older consultants still want to turn up at 8 am and go home at 6 pm, Monday to Friday.”
Opting out of the directive
But the one group that has been most outspoken about the impact of any changes on training hours is the Royal College of Surgeons. Could their objections be an obstacle to the changes Temple envisages? Their president, John Black, remains adamant the working time directive has to go because doctors cannot be trained within its time frame. His view is bolstered by a recent memo he received from the new secretary of state for health, Andrew Lansley, which Black believes signals a willingness to opt out of the directive completely.
Mr Lansley has, he says, stated the new coalition government will “examine the balance of the EU’s existing competences and will, in particular, work to limit the application of the working time directive in the United Kingdom.” Additionally, he cites William Hague, the foreign secretary, from an article for a European Commission website written after he took office—“It is, after all, very hard to argue that the hours that medical doctors work is something that has to be regulated at the European level. In fact, such regulation discredits the EU when it creates serious problems for public services, as it has by damaging patient care in Britain.”
And he had a phone call from Lansley the day after the secretary of state’s appointment in which he told Black that releasing junior doctors from the directive was “a very high priority.”
One route out, which Temple’s report was not allowed to consider, he told the BMJ, was getting Europe to change the rules. Temple was not allowed to look at that option because of the trade union bias of the former government, he says.
“I think the Temple report is an analysis of the problem, but he had one hand tied behind his back and he wasn’t allowed to look at whether it might be possible to change the legislation.”
And he’s dismissive of protestations that the directive aims to improve patient safety by reducing the risk of tired doctors working long shifts. “The European Working Time Directive was nothing to do with the safety of patients. It’s entirely about improving the welfare of workers.”
If the Labour government was still in power, one imagines the surgeons’ views might get short shrift. But with Andrew Lansley in power, everyone is waiting to see who is most successful in shouting loudest in the new minister’s ear.
- Temple J. Time for training. A review of the impact of the European Working Time Directive on the quality of training . Medical Education England, 2010. [Link]
Lynn Eaton freelance journalist