Brexit and Medical Training: 2 — working hours
In the year 2000, the EU Working Time Directive was extended to cover some occupations previously excluded from the earlier Working Time Regulations; this short list included doctors. Although the overall hours limits underwent a phased introduction, the general principles of the EWTD has applied to doctors since this date, and has played a major part in determining working patterns for trainees in the NHS.
Most notably, the directive sets an overall limit on the number of hours per week that any employer can require any employee in Europe to work. For professions outside medicine, and some transport workers, the maximum has been set at 48 hours a week since the inception of the EWTD, When junior doctors were first subject to the EWTD, the maximum hours provision was phased in, starting at 58hrs/wk in 2004, coming down 56hrs in 2007 and 48hrs/wk in 2009. Although this is a steep reduction, we need to remember that compared to the massive changes in work patterns that occurred in 2000 to 2004 (which were changes in pay structures, rather than regulations), these EWTD time limits have only had a modest effect on the total hours that junior doctors spend in hospital.
In 2004, in evidence to the House of Lords Select Committee on the European Union, the British Medical Association claimed that while contractual changes in working practices in the early 2000s had reduced total training hours from 30,000 to 8,000 hours per doctor, further reduction in hours by the EWTD would only bring training time down from 8,000 to around 6,000.
Interestingly, the first weekly limits on hours for doctors were introduced as the first New Deal for Doctors in 1991. This “aspired” to a weekly limit of 83 hours by 1993 and 72 hours by December 1994. It failed miserably, principally because there was no robust mechanism to ensure it was enforced. In 2001 a new New Deal was introduced and it was this second reform that catapaulted working hours down from an average of 90/wk to around 50, in just three short years. The secret was simple: hours worked were for the first time robustly linked to the wage that was paid, so that it became very expensive for hospitals to keep junior doctors at work beyond a 56 hour cut-off. Moreover, junior doctors themselves were given the responsibility for monitoring and enforcing the new contract’s implementation.
Thus, when commentators predict that Brexit will inevitably signal a dramatic and unsafe increase in doctors’ hours, they are missing the point that the effect of the hours limits is relatively modest compared to the more important deteminant, which based on the experience of the 1990s historically has been the pay structure for doctors. A note of caution should be sounded, however, in that the pay structure for junior doctors is also being renegotiated currently!
Apart from total hours, the EWTD has had real impact in two other areas of medical working: shift length and breaks between shifts. A maximum shift length of 13 hours, and minimum breaks between shifts of 11 hours has been in place since 2000. This has has a big impact on rota design, but a lesser effect on the real-life working patterns of doctors. The maximum shift length, for example, has proved a real obstacle to delivering continuity of care, especially in the acute specialties such as general medicine and surgery, requiring frequent hand-overs between different shifts of doctors. The effecton real world working patterns has been more limited, due mainly to short staffing, with juniors frequently working well beyond their planned shift patterns.
The obvious question is: how much of this will change with leaving the EU? Unfortunately, due to ongoing negotiations over the junior doctor contract, the precise answer to this remains unclear. It is striking, however, that over recent history it is changes in pay structure, rather than in regulations, that have had big impacts on NHS junior doctors’ working patterns. It seems likely, therefore, that leaving the protection of the EWTD may have big consequences in theory, but is unlikely, on its own, to have large scale impact on the working lives of doctors unless accompanied by wholescale reform of employment contracts.
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