‘THIS major change to junior doctors’ hours is probably the biggest challenge hospitals will face in 2009.’
This is the view of Dr Jonathan Fielden, Chairman of the British Medical Association’s (BMA) Central Consultants and Specialists Committee (CCSC).
He was referring to the fact that a 48-hour-week will be required for trainee doctors as from August 1st 2009, according to the European Working Time Directive (EWTD).
The hours limits have been brought in gradually for junior doctors in the United Kingdom – 58 hours in 2004, 56 hours in 2007 and now 48 hours this August.
The doctors’ union, the BMA, supports the introduction of a 48-hour, maximal, average, working week for all doctors in training in August 2009.
The Department of Health (DH) states that money has been made available in 2008 (£100m) and 2009 (£300m).
However, the BMA points out in its December 2008 press release that hospitals do not know how to access this money from the Primary Care Trusts (PCTs), or the PCTs are not receiving the money.
EWTD used to further the DH’s agenda
Anyone would assume that the reduction of junior doctors hours to 48 hours, after all these years, is a good thing.
However, the move to EWTD compliance is being used by the DH to further its own agenda.
In order to bring the hours down and maintain the same standard of service as exists at present, requires that more doctors be employed.
But this is just what the DH does not want to do.
It is proposing to cut the hours, but in many cases not increase the number of doctors employed.
How can this be done?
1. Hospital at night schemes
One proposal is to reduce the number of doctors ‘on call’ in the hospital at night. This is called the H@N scheme.
The proposal is to have a small generic group of junior doctors covering for many different specialties. instead of several teams of specialty trained doctors as at present.
Thus a SHO could end up covering for patients with conditions, of which he/she had very little knowledge.
2. Nurse Substitution
Proposals are being put forward to substitute ‘nurse practitioners’ for doctors. Nurses’ training is different from doctors’ training and they cannot be expected to recognise a seriously ill patient in the same way.
3. Consultant substitution
The third way, to avoid employing more junior doctors is to call for an expansion of the consultant grade and then expect them to perform the work of junior doctors, in addition to their own work.
For example some medical consultants are being asked to do huge ward rounds of newly admitted patients on acute assessment units, on 11-hour shifts, only accompanied for the most part by House Officers, not a registrar.
Not only is the registrar missing out on the training that the consultant could provide, the consultant has to do all the work, procedures etc that the registrar would have done.
The supposed benefits for the patient of seeing the consultant early on in their admission, are contradicted by the lack of registrar support and the fatigue imposed on the consultant.
This drive is all part of a productivity plan by the DH imposed on hospitals to reduce the patients’ ‘length of stay’.
The greater the patient turnover, the greater the Payments by Results (PBR) tariffs the trust can get.
Trusts are thus financially incentivised to discharge patients sooner.
Gaps in junior doctors rotas already exist
Since the changes to the immigration rules in March 2006, it has become very difficult for international medical graduates to get junior doctor’s jobs in the UK.
In the past, these doctors provided a large part of the middle-grade workforce.
There is now a shortage of junior doctors to fill the rotas.
Junior doctors are pushed to cover for absent colleagues.
The DH has consciously created a shortage of junior doctors, so that the EWTD, can be used to change working practices, introduce substandard H@N teams, and pressurise consultants to do juniors’ work.
Reconfiguration
This manufactured shortage of junior doctors and the EWTD are also being used to push the ‘reconfiguration’ of hospital services.
In his report recommending the closure of Chase Farm Hospital, in Enfield, Professor Alberti used these reasons to argue that the maternity and paediatric units could not be kept open.
The same excuse is being used everywhere.
The attitude of junior doctors
Many junior doctors welcome the proposed reduction in hours. Many already have EWTD compliant hours.
There are others, especially surgeons, that worry that the reduction in hours will result in less training opportunities.
The obvious answer to this is to lengthen the training period. Already training of some junior doctors takes place on reduced flexible hours, for example, women with children, and it is still possible to train them.
Clearly the reduced hours have to be taken into account and training arranged accordingly.
The Royal College of Surgeons, has asked for a derogation from the directive, and suggested that is only possible to train surgeons adequately on a 65-hour week.
The role of the union leadership
The leadership of the consultants’ section of the BMA has been lobbying hard for an expansion of the consultant grade, declaring ‘ . . . there is strong evidence for the need for expansion in numbers of consultants’.
The problem is that this lobbying is starting to look like support for consultant substitution (3).
In the BMA’s Consultant News, February 2009, CCSC Chairman, Fielden, writes: ‘Inevitably much of the workload will move to consultants.
‘As we move to a consultant-based service where most of the medical care is decided or delivered by consultants, our lives and the way we work will change . . .
‘The longer-term solutions are consultant expansion, focused training and educational opportunities and probable reconfiguration of (some) services.’
Later, when issuing its new ‘Guidance on shift and resident working for consultants’, the newsletter states: ‘With the implementation of the 48 hours limit on trainees’ hours due to apply from August, it is likely that gaps in rotas will emerge and consultants may consider increasing hours or working unsocial hours to help maintain high-quality patient care and the service generally . . .’ (emphasis added)
The issuing of the guidance at all is a sign of the times.
It is noticeable that nowhere in the BMA’s statements is there a call for an increase in the numbers of junior doctors employed.
Conclusion
The DH is pushing ahead with the Darzi plans for whole scale ‘reconfiguration’ of hospital services.
The plan is to close many District General Hospitals and replace them with inferior ‘Local Hospitals’, privatised elective centres and polyclinics.
Such entities do not want junior doctors, who are time-consuming to train. The preference of the DH is for nurse practitioners wherever possible.
EWTD is being used as an excuse to reduce the numbers of junior doctors.
The DH hopes to use consultants to fill the gaps and do much more front-line work.
This will exploit present consultants and will result in a significant reduction in the training of junior doctors to become the next generation of consultants.
The DH is clearly moving towards a large contraction in the supply of hospital health services, which tallies with the forecast of huge cuts in public spending by this government as the world crisis bites.
Hospital doctors, juniors and seniors, need to be very aware of the way the EWTD is being used and the BMA needs to confront this challenge, which requires a complete change in direction.
The EWTD implementation should be coupled with an increase in the number of junior doctors so that the next generation of consultants can be trained and our hospitals kept open with properly-qualified staff, providing high-quality care.
