Implications of the European Working Time Directive Phil Baker St Mary’s, Manchester

European Working Time Directive Already applies to consultants. Although most staff do not adhere to EWTD, few have signed derogation agreement Aug 2004: to be applied to Junior Doctors, by introduction of 58 hr ‘max legal average’ working week. All doctors 11 hours rest every 24 hours Aug 2007: ‘max legal average’ working week will be 56 hrs Aug 2009: full implementation of EWTD will result in ‘max legal average’ working week of 48 hrs –NB Resident on call counts as working hours

Other initiatives Calman training scheme: shortened and streamlined middle-grade training New Deal for Junior Doctors: trainees spend less time in hospital – less time for service and training commitment Alterations in SHO training: ‘Unfinished business’. SHO training to be managed, time-limited and structured New Consultant contract

Implications for service 1: ‘Old style’: This will not work after EWTD Trainees contribute a large amount of service workload, esp out of hours. Gained much experience. Out of hours work rarely involved consultants

Implications for service 2: ‘New style’ Trainees will still need to undertake service – but will be governed by needs of learning objectives Service delivery will be provided by trained staff

RCOG standpoint (EWTD) has the potential to disrupt clinical services, to destabilize postgraduate training and to damage clinical standards in obstetrics and gynaecology.

Workforce ,384 consultants in post. 61 vacancies 788 SpRs in post. 43% were visiting (overseas) trainees 1,338 SHOs. 637 non-consultant career grade posts (NCCG). increases of 7% in consultant and 17% in NCCG. reductions of 9% in SpR and 3% in SHO posts. Midwifery recruitment and retention problems

Workforce Reduction in training posts from 98/99 – expected excess of qualified trainees without consultant posts. Excess did not materialise. Lower no.s trainees : insufficient to provide adequate service cover on wards and fill vacant consultant posts in near future. NHS Trusts employ NCCG to cover service gaps. Experienced, not completed structured training programme, less attractive job plans. Exploited and disillusioned. Overseas primary medical qualifications : allegations of racial discrimination. Additional 63 NTNs for 03/4. No extra funding for posts Assuming 5% consultant expansion and approximately 50 retirements/yr: 892 consultant opportunities in next 5yrs. Only 447 career SpRs in post.

Academy of Medical Royal Colleges Suggestions for responding to EWTD Greater use of skill mix; staff other than doctors to carry out tasks traditionally undertaken by doctors Cross-cover: trainees from different disciplines sharing on-call Service configuration: greater differentiation of high and low risk patients Reducing tiers of cover: ?combine consultant and middle grade working patterns

RCOG response Cross cover: obstetrics, requires the constant presence of staff with specific skills…this type of cover …not a realistic option for maternity services Option: Increase rapidly number of trained doctors. Recruitment of new trainees will not solve the problem in next few years. Promotion of NCCG to consultant may exacerbate problems of providing middle grade cover. Option: Expand overseas doctors’ fellowship scheme

Solutions Derogation Move CCST to earlier point in training: ‘generalist’ vs ‘specialist’ Appoint more trainees Overseas trainees Encourage existing consultants to continue Non-medical practitioners Promote NCCG staff (pros & cons) Rationalise number of units Cross cover

Local solution: St Mary’s Hospital Manchester 4500 del/year. Regional referral centre. Complex case mix Current out of hours cover Non resident consultant obstetrician SPR (2 nd SPR in hospital, called <25%) SHO (shift pattern) Not EWTD compliant

Potential solutions Decrease to 1 SPR without resident consultant. Dangerous (Massive risk management issues) and unacceptable to trainees Decrease to 1 SPR with resident consultant. Possible longterm solution – but massive increase in consultant numbers (prior to new contract)

Planned solution Non medical practitioners in Obstetrics and Gynaecology (3+3 to provide cover) Expand middle tier (senior SHO posts) and 2 middle grade on call (1 SPR 3-5, 1 SPR 1-2/SSHO) No SHO on call New out of hours cover Non resident consultant obstetrician 2 middle grade on call 1 Non medical practitioners EWTD compliant

Implications for training Less time available: formal training sessions and ‘apprenticeship’ must take place within normal working hours. 10 yrs ago registrar/senior registrars spent longer in yrs and 100% more time in hospital Expected to train to competence but fewer hrs/week and shorter number of years

Solutions Less skilled, narrower qualification. –? Labour ward obstetrician needs to learn colposcopy Focused targeted training –Eg. Labour ward training scheme

Guidelines Once the log book criteria for a grade have been completed, the trainee can approach any assessor to be assessed for competence at that grade. Cases can then be collected for grades higher than that for which the trainee is due to be assessed (e.g. for Grade 3 prior to assessment at Grade 2). No trainee can be assessed by the same assessor for all grades. The grade of the trainee may move up or down, with the reassessment in either direction being instigated on the advice advice of senior midwifery/obstetrician colleagues.

Grade 1 THIS IS THE ENTRY LEVEL FOR ALL SENIOR HOUSE OFFICERS JOINING THE ST. MARY’S HOSPITAL MEDICAL STAFF  Has been orientated to the labour ward  has attended a neonatal resuscitation session Is competent in the following (recorded and signed in a log) Vaginal assessment in the first stage of labour (x10) We suggest that 5 of these assessments are intrapartum assessments (detailing the station, position, dilatation and the effacement) and that 5 assessments are of the cervix prior to induction of labour (detailing the Bishop’s score) Patient numberDateSignature of assessor (Registrar / midwifery sister)

Satisfactory repair of episiotomies/perineal tears (x6) with the appropriate documentation Patient numberDateSignature of assessor (Registrar / midwifery sister) Successful fetal blood sampling (x6) with the appropriate documentation. Patient numberDateSignature of assessor (Registrar / midwifery sister) Twin delivery (x2) Patient numberDateSignature of assessor (Supervising consultant) 1 2 Repair of third or fourth degree perineal tear (x3) Patient numberDateSignature of assessor (Supervising consultant) Formal Assessment  Competent “evidence based” labour ward practice over a whole range of obstetric emergencies and complicated pregnancies.  To achieve this grade, trainees must be satisfactorily assessed by an informal viva, by three different assessors (consultants) this will include the assessor attending a labour ward round conducted by the trainee. DateMark (out of total 100)* Signature of assessor (trainees should have a different assessor to their assessor at Grade 2) 1 * a mark of 85/100 = Pass 95= Distinction

Grade 4 THE HIGHEST LEVEL ATTAINABLE. We would only anticipate that this Grade was attained by trainees with a particular interest in labour ward management. Candidates should apply for assessment at this grade, by submitting a portfolio of labour ward related activities. Typically, a portfolio will include the following:  Evidence based revisions and updates of labour ward protocols.  Labour ward based audit projects with demonstrable effects on labour ward practice.  Peer reviewed research papers relating to labour ward practice.  Evidence of teaching initiatives – undergraduate/postgraduate level relating to the labour ward. If the portfolio is accepted as of an appropriate standard by the obstetric consultants, the trainee will be invited to undergo a formal assessment by two consultant staff. The assessment will focus on teaching and training, and will incorporate assessment of :- The ability to teach and train junior staff – this will involve attendance at a teaching/training session organised by the trainee applying for grade 4 status. Signature of assessor 1.DateSignature of assessor 2.Date 1