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EUROPEAN WORKING
TIME DIRECTIVE
Introduction
European
working time directive became part of UK law in October 1998 as health and
safety legislation.[1]The law meant to reduce the doctors time in hospitals
concerning the patient and doctors health . At that time junior doctors or
doctors in training (DIT) were excluded from the scheme due fear of
the adverse effects on hospitals .But in may 2000 the agreement was
reached between European parliament and council of Ministers on agreements and
timetable for doctors in training to be included within directive .The directive
will be applied to DITs as follows
- 1 August 2004: maximum 58 hour
week. All rest periods apply
- 1 August 2007: maximum 56 hour
week
- 1 August 2009: maximum
48 hour week (if introduction of the 48 hour week is deferred until 1 August 2012, then a maximum
52 hour week will come into force on 1 August 2009[1]
But
DITs , NHS and consultants are reluctant in
following the directive or are trying to make some way out . I will
discuss about their apprehensions later but
first I will discuss the health and safety problems related to long working
hours on doctors and patients health.
Effects
on doctors health
Working
long hours have adverse effects on DIT health . As soon as
junior doctors enter into hospital workforce they have to take decisions
which have direct implications on patient life and safety , they also have to
maintain good working relationships with other medics, nursing staff and
administration for ensuring the better care of their patients health. DITs also
have to maintain balance between hospital life, social life and personal
life.[2] Sleepless nights have direct effect on DITs health. Sleep deprivation
causes fatigue which can lead to fatal mistakes by doctors . One study in USA
compare 2 groups of doctors in same hospital . One group was doing long
hours of duty and other with short hours of duty with good supporting cover.
They find that doctors with long hour of duties commit serious mistakes than the
other group [3]. Sleep deprivation causes reduction in general quality of life,
less motivation, poor work output and increased risk of accidents [2].
Effects
on patient care
Continuous
wakefulness and moderate alcohol consumption have same effect on body [4]. This
effect maximizes at the end of night shift, which is time for drive to home, and
this increases the risk of accidents. Fatigue also forces the DIT for short
cuts, which can threaten the patient life. Long hours of working also affect the
doctor–patient relationships. One study in Birmingham university medical
school (UK), 39% junior doctors indicated that long hour adversely effect their
work efficiency and 28 percent indicated that long working hour are effecting
patient relationships [5]
I
personally agree with all these findings. I used to work in my house job from
90-112 hours per week and I experiences all these adverse effects mentioned
above. On few occasions I also commit some serious mistakes, which I still
regret. Hospital management should also take in to account that all doctors do
not have same stamina of working and some may feel tired after few hours of
working or they might be suffering from a disease which can effect their
performance.
The
Ditz were excluded in 1998 on the basis that it would cost much to hospitals as
Ditz are 38 percent of hospital workforce. But when the actual cost calculated
after DITs inclusion it only makes
difference of 1-4 percent[6]
Hospitals
that reduce working hours can improve their business because it increases
effectiveness in work thus increases
the overall quality of care, Improved
working relationship among team members; doctors show decrease resistance to
administration to new initiatives due
to general environment of goodwill[2].
Effects
of European working time directive.
The
EWTD will have more profound effect on the hospitals , junior doctors, and
consultants[7]. Small hospitals now have to hire more junior doctors in their
limited budget.
But
junior doctors may not be able to get more patients and will have effect on
their training and small hospitals might
have to close or merge in larger hospitals
to provide more patients to doctors . but it would have political
implications too[7].
Some
specialties like accident and emergency will not be affected as they are
already following the shift system but in some specialties like pediatrics and
maternity wards, which are often hectic, and need night cover will be hit hard.
Junior
doctors especially in surgical
field feel that it would have detrimental effect on their training and fear that
training period might extend. Because they will be doing few procedures in a
limited time. EWTD will also effect the continuity in patient care. if a doctor
is managing patient for more than 24 hours then it helps in creating the
environment of trust between patient and doctor[7]
Extensive
postgraduate training will not be achieved and there might be move to provide
more frequent training programmes that which will ensure that trainee has got
appropriate training in hand just in time ) instead of trained some time ago
which he rarely or never performs. [8]
If
we look at the experience of Dutch in implementing the EWTD-NT . They also face
some difficulties like submitting the hours of duties by hospitals(60 percent of
hospitals were not able to submit appropriate record), no compensation for home
based on call and above all non-compliance by hospitals [9].
There
are also some provisions in EWTD-NT which cause confusion among DITs Among them
is confusion regarding rest period and not including the education and training
time in working time .
Non-compliance
by many hospital trusts is also a problem .Many hospitals will have to hire many
junior doctors and it will increase the burden on hospital management and on
funds. Under the terms trust who fails to cut the number of hours of doctors
will face fines and threat of employment tribunal .Currently 16- 40 percent UK
DITs are working working above the 56 hours a week or without adequate rest
period[10].
Percentage
of PRHO (Pre-Registration House Officer), SHO (Senior House Officer) and SpR
(Specialist Registrar) posts breaching working hours limits. The figures are
based on returns for November 2003:
|
|
England
(Sept
03)
|
Wales
(Nov
03)
|
Northern
Ireland
(Nov
03)
|
Scotland
(Aug
02)*
|
|
PRHO
|
92%
|
100%
|
94%
|
81%
|
|
SHO
|
85%
|
61%
|
68%
|
41%
|
|
SpR
|
80%
|
40%
|
50%
|
41%
|
|
Total
|
84%
|
60%
|
72%
|
50%
|
·
Total
New Deal compliance in Scotland for August 2003 was 73%; figures by grade were
not available.
Table source = [10]
Solutions
to problems .
There
should be a basic change in health care delivery system .Instead of
providing health care service to every corner of country will not
guarantee good health care so there should be centralization of health care
services so that people get health service at some distance but of high quality.
consultants are also reluctant to follow EWTD because of long tradition of not
working out of hours in hospital. They have to change their behaviors in
compliance with new directive[11]
There
is also need for more doctors in UK .In recent years there has been surge in
doctors from developing countries (especially from India) by passing the PLAB
(The Professional and Linguistic Assessment Board) exam conducted by GMC . But
it also raises the issue of brain drain in developing countries as they are
already deficient of efficient doctors.
So there is an urgent need of increasing the number of medical schools
but it will take 4-5 years to replace any gap. There is also plans of learning
the multiple skills by doctors and nurses to
share the load of other specialities
Pilot
projects
Hospital
at night concept[12]
Currently
19 hospitals are running pilot project of “hospital at night” in England. The
hospital at night was original concept of Dr.Elizabeth Paice ,Dean Director for
London Deanery . the aim of project was to alleviate the effects of full shift
working , brought about by EWTD In
this project nursing staff takes the responsibilities of junior doctors and work
as a team with senior registrar and consultants . Team also share the burden of
other specialities which are going heavy. There has been mixed response for this
project some junior doctors feel that they have to take orders from senior
nursing staff and they work as clerks and technicians instead of doctors. Some
are skeptical about giving the nurses the role of doctors as they are trained
differently and some patients wishes to be seen by doctors instead of nurses. Nurses
take more power from setting up ventilators to prescribing antibiotics. It also
means that workload during night will increased . it facilitates junior
doctors to do some other things like going to operation theatre and they
do not have to be present all the time in wards[12].There is also
use of modern IT tools for working at night like mobile phones ( time saving), electronic
patient record reduces the margin of error and rapid approach to patient
problem) and telemedicine( in which the on call consultant from home can
diagnose the cases and can give advice).
Conclusion
.
EWTD
will change the way the hospitals work so it will take time to all
concerned parties to accept this change .Like
every law ,EWTD is not the perfect solution for everyone [9].So hospitals
and doctors have to adjust themselves with the new realities. As there is
no way out of this law .EWTD is still achievable as other countries (Dutch) are
following the EWTD. There are some problems but they will be solved
with time and policy makers should
make some amendments regarding the controversial points.
Long
hours of working were part of DITs life but now importance of patient and doctor
health safety prevails In my personnel view as EWTD is a very good law and all
concerned parties should try to implement this in full strength . Although it
will take some time to understand
the full implications of this directive .regarding the decrease training opportunities
for surgical doctors in training , this issue must be resolved as first priority
by collaboration of DITs ,consultants and BMA.If this issue is not resolved
early
then
it can cause increase efflux of
DITs from UK which will further reduce the number of doctors in UK. Compliance
of hospitals to EWTD should be monitored regularly.
References
1.Sally
.W.
Inquiry into the European Working Time Directive (EWTD) - evidence from the BMA
House of Lords Select
Committee on the European Union Sub-Committee G (Social Policy and Consumer
Affairs)
February
2004[online].Available at http://web.bma.org.uk/ap.nsf/Content/ewtd0204.[accessed
on 11 nov 2004]
2.ANDREW
.L. Safe working hours - doctors in
training
a best practice
issue[0NLINE]
AHR Article - December Vicdoc.Available from
http://esvc001390.wic013u.server-web.com/AHR%20-%20second%20last%20draft.pdf
[Accessed on 13 dec 2004]
3.Christopher
P. Landrigan, M.D., M.P.H., Jeffrey M. Rothschild, M.D., M.P.H., John W. Cronin,
M.D., Rainu Kaushal, M.D.
Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive
Care Units. N Engl J Med 2004 Oct 28; 351:1838-48.
4.Dawson D & Reid K 1997,
'Equating the performance Impairment Associated with Sustained Wakefulness and
Alcohol Intoxication' (pre-press manuscript), Centre for Sleep Research, School
of Psychology, University of South Australia.[online].available at http://cf.alpa.org/internet/projects/ftdt/backgr/Daw_Lam.html.[accessed
on 17th dec 2004]
5.Samkoff JS & Jacques CHM
1991, 'A Review of Studies Concerning Effects of Sleep Deprivation and Fatigue
on Residents' Performance' Journal of Academic Medicine,
November vol 66 no 11, pp687-693.
6.Australian Medical
Association Limited 1995-2000, 'Overseas Experience in Regulating Hours of Work
of
Doctors In Training' Part 2 -
Detailed Country Profiles.[online].Available at http://www.ama.com.au/web.nsf/doc/SHED-5G2V8T.[Accessed
on 17th dec 2004]
7.Lynn .E.The European working
time directive:
the final countdown
BMJ Career Focus, Jun 2004; 328: 229.
8. Sir Graeme C.Education and training within the
European Working Time Directive.BMJ
Career Focus, Aug 2002; 325: S69.
9. Fleur .S.The Dutch experience of
implementing the European Working Time
Directive.BMJ Career Focus, Aug 2002; 325:
S71
10.
Hospital doctors - junior doctors’ hours
May 2004[online].BMA .avaliblnle
at http://www.bma.org.uk/ap.nsf/Content/ewtd0204.[accessed on 15 dec 2004]
11. Paul
Thorpe. Implementing the European Working
Time
directive
on a national level.
BMJ Career Focus 2002;325:67 (31 August).
12. Rhona MacDonald.The Hospital
at Night.MJ
Career Focus, Jan 2004; 328: 19.
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