There is widespread agreement that surgical training has suffered under the 48-hour week, but there is less consensus on how to solve the problem. Paul Brennan reports
More than one year since our working week was formally limited to 48 hours, a survey from the RCSEng has highlighted the effect this is having on training and patient care. They, along with ASiT and BOTA, are keeping up pressure on the government to rethink the EWTD rules, although the BMA and some other EU member states continue to argue for the status quo.
"Before we commit to lengthening the working week again, we should ask what we as trainees want to do in those extra hours"
It’s clear though from the GMC’s most recent survey of training across the medical specialities that surgical training is suffering under the EWTD restrictions (along with paediatrics, O&G, emergency medicine and acute medicine trainees). Furthermore, Sir John Temple’s report into the impact of EWTD on surgical training identifies that the shorter working week has had a disporpotionate effect in reducing training hours rather than service hours. Good news then that the government supports the need for change, but several months into the coalitition’s term, despite ambitious changes for health, social security and defence, we are yet to hear details of how EWTD legislation might be reformed.
How many hours could we or should we work beyond 48? A return to 100+ hours per week is unattractive. Sixty-five hours per week has been proposed. However, before we commit to lengthening the working week again, we should ask what we as trainees want to do in those extra hours. If we can’t also rethink full shift rotas that tend to prioritse on-call work, there is a risk that increased hours simply means more on-call.
Anecdotally at least, trainees in neurosurgery who have ‘opted out’ of the 48-hour limit report an increase in on-calls and unsupervised clinics with no significant improvement in training – although there are certainly training opportunities in the clinic and on-call.
The problem of trainees not being ‘on the ground’ enough to maximise exposure to learning opportunities is exacerbated by rota gaps that have proliferated since MMC led to a reduction in the numbers of junior doctors avilable to fill them. Trainees often provide internal locums to fill these gaps. Since trainee numbers are generally set to reduce, this situation will not improve without a change in rota design and the way we deliver care.
On this point, the Temple Report recommends centralisation of delivery of out of hours care as a solution to filling on-call rotas with fewer trainees, as well as a move towards a consultant-led service to free up trainees for training. The former is a political hot potato. The latter appears to be moving up the political agenda. We need to give serious consideration to how it might work, and if it won’t work, to be ready to say why. Any rethink in the way care is delivered by ‘trained’ surgeons will also have to consider the impending bulge of trainees at CCT in the near future without any obvious further consultant expansion on the horizon.
So, whatever the political will, rethinking the 48-hour week in isolation will not be easy. This is perhaps why the Temple Report recommends focusing on improving the quality of training within a 48-hour model (also the policy of the Edinburgh College). A BMA-led group looking at how to optimise surgical training within the 48-hour week is expected to report early next year. With representatives from ASiT, BOTA, GMC, Deanaries, and the Royal Surgical Colleges, hopefully this will result in clear and useful guidance for best practice.
The Edinburgh College is also looking at how to better identify and support surgeons who are the best trainers. As trainees we can perhaps focus on what we can achieve ourselves outside the 48 hours – simulation, reading, research – to enhance our own training rather than leave this to NHS managers to decide how we fill our time by simply extending the working week.
There is a lot at stake and it’s important that trainees input into informing and shaping the College’s agenda on these issues. The new trainee representation structures reported elsewhere in this issue should facilitate the gathering of opinions on these topics.
Paul Brennan, Clinical Lecturer and Honorary Specialist Registrar in Neurosurgery, Edinburgh Cancer Research Centre, Western General Hospital, Edinburgh