According to a report into the state of hospital care and junior doctor training published last week by the Royal College of Surgeons, European rules that govern their working hours are actually putting patients at risk. But most of us knew this already.
The report found that, due to the European Working Time Directive (EWTD), junior doctors today have 128 fewer days of experience when they qualify as specialists. Introduced in 1993, the directive was originally intended to prevent long-distance lorry drivers from falling asleep at the wheel, but it has since been applied to doctors with the intention of improving safety and patient care. It ensures that all junior doctors – classified as any doctor in training below the grade of consultant – do not work more than 48 hours a week over a 26-week period. Since 2009, they may not work continuously for more than 13 hours and must have a break every six hours.
On the face of it, this seems sensible. No one wants to go back to the dark days when juniors routinely worked 90 hours a week. But the change has had unintended consequences.
The rigidity of the rules means doctors are expected to down tools the minute they have worked their allotted hours. The New Deal – an agreement between the Department of Health and the British Medical Association – has instituted punitive measures against hospital trusts that fail to comply with the EWTD. It requires absolute compliance; if one doctor works half an hour over the stipulated time, the entire rota is deemed to have been “breached” and severe financial penalties will be incurred. The report has found that many trusts have cancelled clinics or appointments as no doctors were available to run them.
While junior doctors are allowed to opt out of the EWTD, many trusts discourage the practice because they are reluctant to pay overtime. Instead, there is implicit pressure on junior staff from senior doctors and management to lie on their working hours forms. We all know that if we tell the truth, the trust will be fined, its debts will increase and redundancies will follow or services will be reduced. The loser is always patient care.
Meanwhile, there is resentment among hospital doctors who are not being paid for the work they do, staying behind long after they should have gone home.
Even more worrying is how the EWTD has fundamentally altered the way medical care is delivered. There has been a cataclysmic “decoupling” of the junior workforce from the seniors.
Prior to the EWTD, junior doctors were attached to a team typically comprising a newly qualified doctor, a senior house officer, a registrar and a consultant. This “firm”, as it was known, was a tried-and-tested way of delivering care. The most junior members learnt from the registrar who, in turn, learnt from the consultant. Roles and responsibilities were clear and there was a sense of belonging, which ensured that juniors would follow their patient from the moment they were admitted or seen in clinic to the point of discharge. There were clear lines of accountability.
But juniors are no longer routinely attached to a particular consultant or team; rather, they “float” between teams, providing cover ad hoc. Both patient and doctor are casualties in this. Junior staff are expected to perform their jobs with no understanding of how their actions impact on wellbeing. There is no appreciation of cause and effect, and no true ownership of the work done.
It is common for patients never to see the same doctor more than once. They often feel confused, isolated and scared at the lack of continuity, having to explain the same problem to every new doctor. Things slip through the net. It is not safe.
Doctors don’t want to work like this. We feel like automatons clocking on and off. The EWTD destroys any sense of vocation in our work and removes the opportunity to learn from our seniors, to develop a relationship with them and their patients.
It is only right that junior doctors are freed to provide the care that their patients deserve and that they are paid for the work that they do.
Max Pemberton’s latest book is The Doctor Will See You Now.