Policy responses and statements

Name of organisation:

NHS Medical Education England (MEE)

Name of policy document:

Review into the Impact of the EWTD on Quality of Training - Invitation for Written Evidence (The Temple Review)

Deadline for response:

18 February 2010

Background: The former Secretary of State for Health, Alan Johnson, commissioned Medical Education England (MEE) to undertake a review into the impact of the European Working Time Directive (EWTD) on the quality of postgraduate training for doctors, dentists, healthcare scientists and pharmacists. Professor Sir John Temple has been asked to Chair this review.

It is vital that the review thoroughly assesses all issues and opinions on this critical topic. Over the coming months MEE will be collecting evidence from a wide range of people and organisations involved in the training of healthcare professionals including trainers, regulators, training institutions, Royal Colleges and Faculties, employers and trainees. MEE will produce a report on the impact of the EWTD on the quality of training, including recommendations, which can then be put to the Secretary of State for Health in spring 2010.

RCPE has already received an invitation to attend an oral evidence gathering session in January and in conjunction with this MEE is inviting the College to submit written evidence to inform the review. MEE would like RCPE to respond to four questions which will help it understand how high quality training is to be delivered within the constraints of the EWTD. The College is asked to extend the invitation to submit written evidence to the trainee representative committee of RCPE and the professional organisations associated with our specialty to ensure that MEE get as wide a range of views as possible.

Further details of the review and how to submit written evidence in the attached document or on the MEE website- MEE EWTD Review. A letter inviting RCPE to submit written evidence has also been sent to us in the post. All evidence will be drawn together to produce the final report.

There will be additional opportunities for oral review and debate in March 2010 after the draft report and recommendations are produced.

COMMENTS ON
NHS MEDICAL EDUCATION ENGLAND (MEE)
REVIEW INTO THE IMPACT OF THE EWTD ON QUALITY OF TRAINING - INVITATION FOR WRITTEN EVIDENCE [THE TEMPLE REVIEW]

The Royal College of Physicians of Edinburgh is pleased to respond to NHS Medical Education England on The Review into the Impact of the EWTD on Quality of Training - Invitation for Written Evidence (The Temple Review):

1. The College has led the work of the Scottish Academy in surveying Fellows and Members across the UK on the early impact of the EWTD. The resulting data has been shared with Fellows and Members and with Health Departments in England and Scotland. The College offers the English data to the Temple Enquiry as evidence to inform their work on the impact of EWTD on training.

Expectations immediately before the EWTD came into effect

2. In December 2008, in anticipation of implementation of the 48 hour working week, 84% of  physicians responding in England  (n=373) expected the 48 hour working to impact negatively on training. When the responses of the medical managers were considered in isolation, 87% agreed they anticipated a major impact on training

Compliance with 48 hours (autumn 2009)

3. In the first few months following the implementation of the EWTD a Scottish Academy multi specialty survey captured worrying views from 766 consultants and trainees in England (majority surgeons and physicians). 90% believed their new rotas were fully or partially compliant on paper but only 58% believed this was happening in reality.

Impact of EWTD on training

4. A significant majority of respondents (72%) felt the EWTD was already having an adverse effect on training. This was the most extreme of all issues tested and was agreed by a higher percentage of consultants (79%) than trainees (69%).

5. The qualitative information provided by respondents articulates clearly the nature of adverse impact:

6. Difficult shift patterns and multiple handovers resulted in reduced continuity of care, increased risk to patients and lost learning opportunities through no follow up of patients.

7. Rota patterns to achieve 48 hours were causing trainees to miss outpatient clinics, teaching lists and ward rounds. This is of particular concern for specialty training with missed teaching sessions (elective lists, clinics, procedure sessions etc) due to trainees covering more general duties in wards, on call duties or rostered off duty.

8. Gaps in the rotas due to vacancies, maternity leave and sickness were adding to the pressure on trainees and limiting teaching opportunities further. Trainees felt under pressure to stay beyond hours for patient safety reasons and to support their colleagues. There were also reports of trainees coming under pressure to cover their own locums and some reports of trainees being encouraged to “fix” their rota monitoring returns.

9. There is even less opportunity for consultants to work with their allocated trainees and this limits teaching, assessment and mentoring opportunities. Many expressed concern about inadequately assessed/trained consultants in the future and worries about erosion of professionalism and work ethic.

10. Planning is badly disrupted by trainees being reallocated to cover emergency call and ward duties at short notice, by wasting training opportunities set up for them and also causing disruption to patients in over booked out-patient clinics.

11. Surgical trainees were concerned particularly about cross speciality emergency cover and limitations on learning opportunities within speciality as a result out-of-hours duties.

12. Trainees accept that service provision provides a rich training environment but they feel the balance has shifted completely towards service with consequent disruption of their training and erosion of their quality of life through difficult rota patterns. Some felt that employers’ threats of imposing shifts may be stifling complaints.

Suggested Solutions

13. The College understands that a return to long working hours is unlikely and indeed is distinctly undesirable in terms of the impact on patient safety when care is delivered by over-tired doctors. Therefore solutions must be found to address the adverse impact on training that is already being felt and which may deteriorate further. Moreover, we must address the demoralising effect of changed working patterns for trainees and trainers in the NHS.

14. The College suggests the following are worthy of further exploration and would be keen to contribute it’s expertise to help to address these issues in the near future:

• Accreditation for trainers - recognising training as a special interest and ensuring all trainees are supported by effective trainers with adequate SPA time in their job plans to deliver the training as set out in the curricula and assessment blueprints developed by the Colleges and approved by PMETB. To some extent this has already been recognised by Lord Patel in his report to the GMC/PMETB (Report of the Education and Training Regulation Policy Review: Recommendations and Options for the Future Regulation of Education and Training).  This could result in some consultants becoming primarily trainers in the future.

• Accreditation for training for hospitals or units - where service configuration and performance targets are designed to deliver high quality patient care and high quality training programmes. The transition away from teaching status (and funding) for units not so accredited would require careful management to protect patient safety.

• Formal commitment to excellence in training – training quality should be defined by standards (see accreditation solution 2 above) and there should be an identified Board level person with responsibility for medical education in all hospitals/units accredited as a training organisation. The quality of training should become a key performance target for Boards and the senior managers of those hospitals and/or units accredited for training.

• Adequately staffed trainee rotas - to limit the disruption to planned teaching by emergency re-allocation of trainees to cover service gaps. These result from recruitment failure, maternity leave, study leave and sickness absence with limited locum availability beyond asking other trainees to support their own locum shifts. The NHS must allow for sufficient capacity to absorb predictable levels of absence to protect patient safety and sustain training. Options include providing opportunities for overseas doctors to cover gaps with short-term high quality training attachments. The College has created a scheme to provide high quality doctors for these opportunities. 

• More opportunities to recruit - moving from an annual recruitment round to increase opportunities to fill gaps created by recruitment failures more quickly. The College does not recommend a return to open recruiting.

• Service reconfiguration – to address out–of-hours and emergency pressures for trainees and consultants. The College believes that local clinical leaders should work closely with hospital managers to ensure that the quality of service and training standards are addressed in future service reconfigurations.

• Changing work patterns for consultants - to support the delivery of high quality care during on-call and out-of-hours commitments.  Rotas must create capacity in consultant job plans to provide senior cover over the extended working day to enhance patient care and support training and assessment opportunities. Workforce planning models must take account of the need for additional consultants to deliver this change and which in turn will influence the numbers of trainees.   .

• Sharing best practice in rota design – medical managers must recognise differences in work intensity within disparate areas of the hospital and deliver rotas that optimise the time that clinical and education supervisors have available to work with, observe and mentor their allocated trainees.

• Recognising training opportunities within the multi disciplinary team –trainees benefit from training delivered during service provision by senior nursing and allied health professional colleagues. Trainers must explore ways of accrediting and documenting this training as part of the assessment of trainees. .

• Investment in innovative training technology - including software packages and simulation equipment.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[17 February 2010]