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European Working Time Directive (EWTD) and the NHS

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What is the EWTD?

No legislation from the European Union has affected the NHS more than the European Working Time Directive (EWTD). The EWTD was devised by the European Commission to protect the health and safety of EU workers by restricting the number of hours an individual can work while also imposing minimum rest requirements.[1] Its main features include:

  • Working hours reduced to 48 per week, calculated over a six month period.
  • A period of 11 hours of continuous rest each day (or compensatory rest taken at another time).
  • A day off each week or two days off every fortnight.
  • A 20 minute break for work over 6 hours.

These measures were fully implemented across the NHS on the 1st of August, 2009.[2] The EWTD also states that time spent on call or any time at the place of work counts as working time, regardless of whether work is actually done. Non-compliance results in fines, tribunal proceedings brought by employees and the possibility of the Department of Health being subject to enforcement proceedings by the European Commission.[3] Individual doctors can opt out of the EWTD. This is a voluntary decision and employers who put pressure on staff to do so can face serious penalties. GPs do not fall inside the EWTD as they are self employed.[4]


Advantages

There is little doubt that working hours needed to fall.[5] The EWTD’S limits to working hours have one major advantage: they reduce the likelihood of medical staff becoming tired and burnt out, thus improving patient safety and the quality of care provided. There is little debate that staff fatigue has a big effect on patient safety, especially in high risk surgical practice.[6] Furthermore, a recent investigation presented in the BMJ found ‘no evidence that implementation of the European Working Time Directive has led to a decline in the quality of training.[7] National and international comparisons have also confirmed that high quality training can be delivered within reduced working hours.[8]


Disadvantages

‘The one size fits all approach of the Working Time Directive in medicine is detrimental for training and patient care in some specialties’ – Professor Norman Williams, Former President of the Royal College of Surgeons

A government commissioned review of the impact of the EWTD (chaired by Sir John Temple) claimed that, although high quality training can still be delivered within a 48 hours’ working week, trainees with a major role in out of hours services, or those who are poorly supervised or with limited access to learning opportunities will struggle to become as well trained as those that went before them, pre-EWTD.[9] A major problem with enforcing reduced hours on the medical professions is the fact that their expertise involves a lot of experiential learning. For example, in specialisations requiring the mastery of complex practical procedures, doctors have protested at the harmful impact shortened hours might have on the amount of cases treated by juniors and the consequent reduced opportunities to obtain vital skills.[10] Some trainee surgeons are forced to work longer hours voluntarily to give them the training they need (there are now around 15,000 training hours available over a typical seven year training programme).[11] Other countries in the EU similarly argue that training hours must be protected from the EWTD.[12] Frequent rota gaps have formed due to its implementation. This has caused locum and agency staff to be used ever more frequently,[13] and also has meant that trainees are often moved at short notice from their planned daytime training commitments to fill such gaps.[14] The resultant fragmentation of teams has led to inefficiency and poor continuity of care for patients.[15] In a ‘free text’ opinion survey of nearly 2,500 doctors, 11 per cent made unprompted reference to the EWTD, claiming that some hospitals were persuading junior doctors to collude in the inaccurate reporting of their compliance while also citing an adverse effect on training opportunities due to the EWTD.[16] Shorter shifts have also increased the number of handovers needed between doctors, increasing the risk of errors.[17]


Conclusion

Whatever the solutions, it seems clear we should not return to doctors working excessively long hours.’[18] Despite this, there are indications that a one size policy is inappropriate for all the heterogeneous working groups inside the NHS,[19] but the problem of safeguarding staff against fatigue and burnout remains. For example, surgeons need to be properly rested to be safe; but conversely they require the most hours of training. Undoubtedly NHS working conditions have been improved by the EWTD, but now we are challenged to ensure the British healthcare system still provides the highest standard of training and patient care.

 

  •  Edmund Stubbs – Health Research Fellow

 

Notes

[1] ‘European Working Time Directive: Junior doctors FAQ’, The BMA, 2016, https://www.bma.org.uk/advice/employment/working-hours/ewtd-juniors-faq

[2] ‘European Working Time Directive’, NHS Employers, 2009, http://www.nhsemployers.org/your-workforce/need-to-know/european-working-time-directive

[3] ‘European Working Time Directive’, NHS Employers, 2009, http://www.nhsemployers.org/your-workforce/need-to-know/european-working-time-directive

[4] ‘European Working Time Directive’, Royal College of Surgeons, 2016, https://www.rcseng.ac.uk/fds/nacpde/eea-qualified/ewtd

[5] S. Datta, J. Chatterjee, D. Roland, J, Fitzgerland, D. Sowden. ‘The European Working Time Directive: time to change?’, BMJ Careers, 2011, http://careers.bmj.com/careers/advice/view-article.html?id=20004482

[6] S. Chapman & A. Bhangu, ‘European Working Time Directive: More harm than good for surgical trainees’, BMJ, Vol 349, g7323, 2014, http://www.bmj.com/content/349/bmj.g7323/rr/826511

[7] A. Hartle, S. Gibb, A. Goddard. ‘Can doctors be training in a 48 hour working week?’, The BMJ, 2014, http://www.bmj.com/content/349/bmj.g7323

[8] J. Temple et al, ‘Time for Training’, Health Education England, 2010, https://www.hee.nhs.uk/sites/default/files/documents/Time%20for%20training%20report_0.pdf

[9] J. Temple et al, ‘Time for Training’, Health Education England, 2010, https://www.hee.nhs.uk/sites/default/files/documents/Time%20for%20training%20report_0.pdf

[10] J. Maisonneuve, T. Lambert, M. Goldacre, ‘UK doctors’ views on the implementation of the European Working Time Directive as applied to medical practice: a qualitative analysis’, BMJ Open, Volume 4, Issue e004391, 2014, http://bmjopen.bmj.com/content/4/2/e004391.full

[11] ‘More flexibility for NHS doctors under European Working Time Directive’, Department of Health, 2014, https://www.gov.uk/government/news/more-flexibility-for-nhs-doctors-under-european-working-time-directive

[12] S. Chapman & A. Bhangu, ‘European Working Time Directive: More harm than good for surgical trainees’, BMJ, Vol 349, g7323, 2014, http://www.bmj.com/content/349/bmj.g7323/rr/826511

[13] B. Gami, ‘Locum Doctors: Patient safety is more important than the cost’, International Journal of Surgery, Volume 12, Issue 2, Pg 189, 2014, http://www.journal-surgery.net/article/S1743-9191(13)01113-8/abstract

[14] J. Temple et al, ‘Time for Training’, Health Education England, 2010, https://www.hee.nhs.uk/sites/default/files/documents/Time%20for%20training%20report_0.pdf

[15] S. Chapman & A. Bhangu, ‘European Working Time Directive: More harm than good for surgical trainees’, BMJ, Vol 349, g7323, 2014, http://www.bmj.com/content/349/bmj.g7323/rr/826511

[16] J. Maisonneuve, T. Lambert, M. Goldacre, ‘UK doctors’ views on the implementation of the European Working Time Directive as applied to medical practice: a qualitative analysis’, BMJ Open, Volume 4, Issue e004391, 2014, http://bmjopen.bmj.com/content/4/2/e004391.full

[17] ‘More flexibility for NHS doctors under European Working Time Directive’, Department of Health, 2014, https://www.gov.uk/government/news/more-flexibility-for-nhs-doctors-under-european-working-time-directive

[18] ‘More flexibility for NHS doctors under European Working Time Directive’, Department of Health, 2014, https://www.gov.uk/government/news/more-flexibility-for-nhs-doctors-under-european-working-time-directive

[19] S. Chapman & A. Bhangu, ‘European Working Time Directive: More harm than good for surgical trainees’, BMJ, Vol 349, g7323, 2014, http://www.bmj.com/content/349/bmj.g7323/rr/826511

 

Picture: Russell Watkins/DFID