Peer into the heart of the tumult surrounding the Government’s NHS reforms, and at the centre there’s the pretty uncontroversial principle of putting doctors, not managers, at the heart of our National Health Service. A hefty shift in this direction has been long overdue. But I have consistently argued through a ten-minute rule Bill, a back-bench business debate, and in questions to the Prime Minister, that any policy to empower our clinicians against the management-speak wielding bureaucrats must tackle the disaster that is the New Deal, (limiting doctors’ hours to 56 hours per week) together with the European Working Time Directive – which limits junior doctor working hours to 48hours per week.
Last week, the Royal College of Physicians published a concerning report: ‘Hospitals on the Edge’. They warned not only of very significant demand-side challenges – dramatically increasing numbers of patients, as well as changing needs of those patients, but of more controllable factors: the current organisation of hospital care. Problems include a dramatic reduction in continuity of care, and a ‘looming workforce crisis in the medical workforce’.
One of the biggest factors identified in this workforce crisis was “the reduced working hours of junior doctors imposed by the New Deal and the European Working Time Directive”. The report suggested that continuity of care has been affected (meaning that the patient sees more doctors, with more hand-overs, where crucial clinical details can get lost under time pressure and things can go wrong); that trainee doctors do not get the same kind of quality interaction with their trainers, and that enforced compensatory rest (as specified under a bizarre European Court of Justice Ruling) is depriving trainees working at night of daytime training opportunities. The report also points out that ironically, the shift-patterns imposed by the EU Working Time Directive and New Deal, which were supposedly intended to make junior doctors' training less arduous, has actually made their quality of life worse.
The scale of the challenges outlined in the report suggests urgency. But these warnings about the European Working Time Directive and New Deal are nothing new. They echo concerns repeated again and again by other doctors’ groups. The EU has officially no jurisdiction over nation states’ health services, but the Directive was introduced as part of EU health and safety law. The BMA welcomed the directive in, arguing that it would prevent the damaging 100 hour weeks worked by junior doctors of old. No one wants to return to those bad old days, but non-unionised, respected medical groups and other Royal Colleges have been warning ever more loudly that the EU directive, in conjunction with the ill-conceived ‘New Deal’ is having a devastating affect on patient care, the training of our consultants of the future, and, ironically, junior doctors’ welfare.
These groups do not want unlimited working hours for junior doctors – the Royal College of surgeons suggests up to a 65 hour working week would be appropriate – but the key is flexibility for professionals to determine their own working and training, with a constant eye to patients’ safety, not ticking management boxes. The BMA is now looking increasingly isolated in its odd insistence that all is fine and dandy with the directive, and nothing needs to change.
The Royal College of Surgeons has estimated that as demands on our NHS rocket, the European Working Time Directive has resulted in the loss of around 400,000 hours (that’s 45 years) of surgical time per month. Hospitals struggling to meet gaps in cover are forking out extortionate sums for locums – with cases of temporary locum doctors being paid £20,000 per week. In total, £2bn has been spent on temporary staff in the NHS.
The Association of Surgeons in Training report in a survey that two thirds of trainees believe that their training has seriously deteriorated since the introduction of the directive.
And when it comes to quality of life, a junior doctor I spoke to recently put it as starkly as this: “The directive certainly hasn’t made any impact on quality of life. Having worked 60-70 hours per week, now doing 48 hours, I am no less tired. The stated aims of improving work-life balance are farcical…” He went on to describe how doctors in his generation know that they cannot get sufficient training in their 48 hour limit, and go in on their days off, often doing as much work as before, but now more tired, and unpaid.
But as the ‘clock-on, clock-off’ culture imposed by the combination of the Working Time Directive, and ‘New Deal’ ( which limits doctors to 56 hours per week), takes effect, a new generation of doctors are being trained with this ethos drummed into them, knowing nothing else. This gradual erosion of the professional ‘go-the-extra-mile’ ethos of the majority of our clinicians, most of whom see patient care as a vocation, not a ‘clock-off’ work shift, poses a terminal threat to our NHS.
Why? Because the calibre and extraordinary dedication of our NHS clinical professionals is largely what enables the NHS to withstand structural change and keep working. If we sit back and watch this professionalism and internationally respected expertise of our medics erode under the misguided dogma of Europe, and the ill-conceived New Labour ‘New Deal’, no amount of structural reform will be able to resurrect what we hold so dear in our National Health Service.
This really matters. If we are to continue the mission to put doctors' ability to care for patients at the heart of our health service, the Government needs to dedicate the same stony determination to stop the daily damage that this EU Directive is causing patients and doctors, as it did in rolling out its structural NHS reforms. The Government is taking this seriously, and is looking to Europe for a solution. But looking to Europe for a solution has so far produced as much progress as waiting for Godot. We need more. Look out for a further investigation and analysis of options coming soon for the Government to act on.