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 equivalent
X
• Membership/Fellowship of Royal College
X
• 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
Generality
not Speciality
Limited learning
Enforced rest
Rota Gaps
(usually out of hours)
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
• UK
Med students
Residents
60 m
8,000
50,000
• Canada 30 m
3,500
10,000
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
Resident
Graded supervision
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
Service

< Trainees
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
‘Training today is patient safety
for the next 25-30 years’
• We must produce
Competent, confident and safe doctors
who will embrace life long learning.
EWTD – the fine points
•
Introduced
•
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
1998
Time for
Training
A review of the impact
of the European Working
Time Directive on the
quality of training
Professor Sir John Temple