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September 29, 2010

Dr Phil’s Private Eye Column, Issue 1272 September 29
Filed under: Private Eye — Tags: — Dr. Phil @ 3:58 pm

The European Working Time Directive again.

Is it possible to train doctors properly in a 48-hour working week? The European Working Time Directive (EWTD), which enforced its final hours’ restriction last year, was agreed in 1999, giving the NHS ten years to prepare. The rationale was sound – there is overwhelming evidence that sleep deprivation and unnatural sleep cycles contribute to thought and movement impairments, injuries and error – but there were obvious dangers too. Halving the working hours of junior doctors could – unless cleverly executed – have a disastrous effect on both training and patient care.

The widespread training failures and alarming drop-out rates publicised in The Times suggests that the NHS, and the Labour government, buried its collective head in the sand over the EWTD. This was hardly new to Eye readers. Back in 2002, MD argued that specialties such as heart surgery needed to merge into fewer units, with a minimum of 4 surgeons, to allow proper training and supervision of those whose hours were restricted. Labour was ‘not persuaded’ by centralisation and we ended up with Oxford heart scandal, where an inexperienced consultant had no senior support or supervision in the hospital when four babies died (Eyes passim)

In July 2003, the Eye reported a survey of 211 hospitals which found that 166 ‘do not have sufficient numbers of specialist registrars to give continuous cover of acute medical admissions. These hospitals have less than 10 specialist registrars in medicine, with 44 having fewer than five and, at present, completely unable to cope with the EWTD. The drastic reduction in hours in the current system will also have a dire effect on surgical training, with many new consultants already unsafe to independently cover all of the operations in their job description.’

The EWTD could only ever have been safely implemented with a redesign of the service, working across teams and merging units to concentrate manpower. Homerton hospital started planning for the EWTD give years ago and have implemented it successfully by separating emergency and elective patients, extending consultants’ hours and designing a well-staffed acute care unit to ensure patient get properly treated while doctors get properly trained. It’s required a cultural shift that’s beyond the ingrained rivalries in many hospitals and gave consultant Dr Croakley ‘many sleepless nights’. But it works because all the staff – junior and senior – had input into the changes and agreed them. In most of the NHS, change is enforced at the last minute with no discussion, and whistle-blowers are shot.

NHS hospitals that didn’t plan for the EWTD are in chaos, made far worse by Labour’s imbecilic decision to send home the thousands of excellent and experienced doctors from India, Pakistan, Egypt and elsewhere who have kept the NHS afloat. These doctors provided both excellent care and training, and the theory that newly qualified British graduates or an influx of European graduates could fill such a gap has proved disastrously optimistic. The result is that there aren’t enough experienced doctors, and novice juniors are marooned on night shifts, covering dozens of patients across multiple wards with little or no supervision. No wonder they’re throwing in the towel.

As one junior put it: ‘Our rotas in most acute specialties are 30% down, so the NHS is having to pay us to do the shifts. Some places are exploiting juniors by getting them to sign EWTD forms that lie about their hours, but most places are just accepting it. The problem is that if you do, say, an extra night you then miss two days of training during the day time. We need to go back to a firm based structure, working in a team, and with more junior doctors. But the juniors we have either aren’t experienced enough or just can’t get on to specialist training.’ Over to you Andrew Lansley.