Adam Morris: Diagnosis is bleak for junior medics

Published on Monday 24 August 2009 10:20

Junior doctors are now banned from working more than 48 hours a week – surely a good thing? As Health Reporter Adam Morris discovers, not everyone agrees

IT HAS been billed as one of the most radical shake-ups to the health service in a generation. Since 1 August, all hospital workers have been legally forbidden from working more than 48 hours in a week.

The European Working Time Directive (EWTD) – which has been brewing in Brussels for years – has split opinion in the medical world, and now there is serious doubt in many circles as to whether or not these rules can be abided by without compromising patient care.

The time and energy of junior doctors – who for decades have filled all kinds of awkward shift gaps in hospitals – now has to be used more sparingly, leaving managers with hundreds of hours worth of gaps in rotas.

Already there have been murmurings that while junior doctors, desperate to impress health chiefs and squeeze in as much learning as they can, are working no more than 48 hours on paper, the reality of shift work is seeing them work many more hours without breaks.

It is one thing to bring in new laws from the EU, but it is another changing the culture of an institution which has long regarded 80 and 90-hour weeks as the norm, and even essential. While many junior doctors are actually happy to put in "silly hours", much like their seniors did in years past, it is the effect on hospital users that is causing concern.

One senior NHS Lothian source said the impact on patients and the health service would be more profound than the education of doctors in training, many of whom spend significant chunks of their own time studying anyway.

"There is no doubt that, in the past, working hours were crazy," the source said. "Experience is key to the apprenticeship and that takes time. The more you see, the more experienced you can become. Working long hours per se is not a good thing, there may be other ways of training more efficiently. But loss of continuity of care affects patients and no-one seems to be in control or overall knowing what is happening. It is the erosion of service that counts here."

Surveys have shown that doctors do not feel the new rules will improve their work-life balance anyway, while in the US the maximum working times often reach 70 or 80 hours per week.

An Edinburgh-based junior medic, who did not want to be named, expressed his concerns about how the new system would work. He said: "The challenge is to ensure that a high level of service can be given to patients within a more restricted time frame. Many senior doctors believe this will mean we as juniors will have to work more effectively and efficiently – however, the workload being what it is, there really is not a great deal of room for improvement.

"Already in many instances, junior doctors are working at maximum capacity. Wards will have busy days where tasks will not be completed within a time scale allotted from Brussels and it is not possible to simply pass these tasks on to the next team, as they will have likewise a hectic workload of their own to contend with.

"I know of many doctors who are staying beyond the time for which they are being paid, simply because it is not culturally or professionally acceptable to leave a colleague with the work you have not managed to complete.

"In working with teams, it is important to help with the workload of another because there will come a time when you depend on their support."

He added that he didn't believe long hours would automatically mean improved care for patients.

"Where is the evidence to show that this leads to a better patient outcome ultimately? It is critically important to judge the level of service not by the clever doctor arriving at a diagnosis but by the patient's own outcome.

"Time spent off the wards may make for more balanced, rested, socially and culturally-attuned doctors who are not diagnostic robots who have lost their human touch."

Another point raised in the debating of these rules was the quality of training and level of experience junior doctors would now accumulate. But as NHS Lothian's medical director Dr Charles Swainson pointed out, there is no reason why, if other EU countries can train medics to an exceptionally high standard in a 48-hour week, Scotland can't too.

Other fears expressed privately within the health board include the possibility of a high-level brain drain – budding doctors who are so ambitious they want to devote their lives to medicine, and will now only be able to that in the US.

Alan Robertson, the chairman of the British Medical Association Scotland junior doctor committee, told the Evening News: "This has being going about for about ten years now, so if health boards weren't ready for it, it would be quite surprising.

"One of our concerns is that while paperwork may be compliant, the reality may be that people have to work more and covering shifts where there are gaps. We could end up with people doing lots of work for nothing, and if this was the case we'd like them to report this to us so something can be done."

NHS Lothian prides itself as being "at the forefront" of educating future medics, according to Paul Padfield, the director of medical education.

Mr Padfield said: "There's no simple answer to this question. It is not an easy matter, but it's a challenge for the whole of the UK. I don't think patient care is being affected."