EWTD

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EWTD New Deal

• Mr Simon Markillie-Mallininson
• Medical HR Advisor
• East Midlands Healthcare Workforce Deanery

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GOOD ROTA DESIGN IS AT THE FOUNDATION OF ANY
SUCCESSFUL SUSTAINABLE EWTD 09 PLANS
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• Working Time Directive
• The European Working Time Directive (EWTD) is
  health and safety legislation and comes into
  effect for doctors in training in August 2004 in
  a staged implementation.
• Post implementation became Working Time
  Regulations (WTR)/(EWTD)/(WTD)
• This deadline is not negotiable. It is fixed in
  law. (Health Saftey)
• There will be no provision to opt-out of any part
  of the requirements.
• Timetable of Implementation

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• The key aspects of the EWTD, as it will apply to
  doctors in training areWorking hours per week
• By August 2004, a reduction to overall average
  weekly working hours of 58 hours
• An interim 56-hour week by August 2007
• A further reduction to 48 hours August 2009 (this
  could be extended to 2012) 
• Rest provisions from August 2004
• 11 hours' continuous rest in every 24 hour period
  
• Minimum 20 minute break when shift exceeds 6
  hours
• Minimum 24 hour rest in every 7 days or Minimum
  48 hour rest in every 14 days
• Minimum 4 weeks' annual leave
• Maximum 8 hours work in 24 for night workers (if
  applicable)

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• Opt Out
• Derogation
• Maximum of 52 hour
• Rest requirements remain
• 5 Trust
• 25 groups of doctors

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What is the problem?

• Easy to construct legally viable rotas compliant
  with New Deal EWTD 09
• Harder to create educationally legally viable
  rotas, which meet service delivery needs
• 2004 solutions unsustainable, eroded training
  morale
• Better approach required for 2009, more time to
  plan

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There is Clear Tension in the System
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There cannot be one size fits all solutions,
as individual situations will differ in many
ways
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1. Basic principles of good rota design

• Consult with all key stakeholders before planning
  any changes
• junior doctors, senior doctors, senior nursing
  staff
• Identify local workload and match medical
  staffing levels appropriately
• Realistic start finish times in the normal
  working day (NWD)
• Minimise impact upon attendance at formal
  teaching sessions
• Include appropriate handover period
• Include appropriate prospective cover allowance
  room for leave to be taken
• Ensure New Deal EWTD requirements are all met
• Ensure rotas are IWL friendly e.g. maximise no
  free weekends

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2. Royal College advice RCP
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• The more shifts that are worked consecutively,
  the greater the relative risk compared to the
  first shift worked

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Even if a seven-night-in-succession rota is
popular with some junior doctors, the health and
safety implications are such that an employer
should impose a change to a safer rota
Designing safer rotas for junior doctors in the
48-hour week RCP, September 2006
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Cell of 10? it is suggested that any fewer
makes the rota unacceptable because, depending on
the specialty and daytime commitment, the service
work will dominate non-clinical work in a way
that would be unacceptable in a training post
Designing safer rotas for junior doctors in the
48-hour week RCP, September 2006
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(No Transcript)
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• Royal College advice RCS

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2. Royal College advice - RCS

• Safe shift working for surgeons in training,
  policy statement updated August 07
• Full shift EWTD negative impact upon training,
  esp in craft specialties
• Sleep loss impacts on learning and memory
  consolidation
• sleep needed after learning a new task to
  consolidate learning
• Need for acute surgical intervention overnight is
  limited
• most work relating to management of medical
  co-morbidities
• Wherever possible senior surgical trainees should
  be removed from night shifts in order to
  consolidate learning and maximise daytime
  training opportunities
• extended day
• daytime emergency lists
• If shift-work is essential
• rota design should follow best practice
• it is not necessarily the number of hours worked
  in a week that causes problems

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2. Royal College advice RCoA

• WTD 2009 and shift working way forwards for
  anaesthetic services, training, doctor and
  patient safety
• Suggest minimum cell of 8
• At least 3 directly supervised half-day sessions
  per week

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• EWTD 2009evidence-based rota planning

• Main complaint in 2004 we never see the
  juniors
• Junior doctors in training
• Sensible to maximise NWD availability re training
  service delivery
• Most formal teaching occurs 9-5
• Theatres, out-patients
• Elective work
• Consultant supervision

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Minimise exposure to night working - health
safety

• Working at night, regardless of the shift
  pattern, can have consequences for both patient
  and personal safety, as it increases the risk of
  making poor decisions or even mistakes
• Working the night shift preparation, survival,
  and recovery. A guide for junior doctors.
• RCP, March 2006

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Minimise exposure to shift-working- impact upon
health

• RCP audits report increased fatigue poor
  performance on night shifts
• Increased risk peptic ulcers, diabetes, heart
  disease
• Women increased risk miscarriages, low birth
  weight babies, premature births, breast ca CHD
• Tolerance adaptation to shift-work decreases
  with age, those aged above 40-45 should work
  fewer night shifts

Implications of shift work for junior
doctors Y.Ahmed-Little, BMJ, 13 April 2007
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Minimise exposure to night working-how?

• Increase pool of doctors providing cover
  overnight
• Employ more juniors
• Hospital at Night
• Reconfiguration or services
• Improve rostering to minimise number of
  consecutive night shifts worked by any individual
• Structured naps may compensate for sleep loss
  published literature on coping with shift-work
  (RCP)

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Results NWD availability over 6 months (on-call
v 56hr 48hr full shift rotas)
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4. Alternative working patterns?
Longer shift lengths require more rest, this may
suit quieter specialties Busier specialties
where little rest is expected can only operate
safely with shorter shift lengths
Rota Design Made Easy, Junior Doctors
Committee, BMA
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Quantifying the risks what the managers see
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What the clinicians see.
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Points to consider with other working patterns

• Must meet New Deal requirements, avoid Band 3
• Rest (nb this will be paid time)
• Shift length
• Local EWTD policy re compensatory rest
• Paid vs unpaid time
• Clinical governance issues
• Non-resident working, is it safe?
• Different juniors like different rotas

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48-hr rotas Non-resident on-call
(7 doctor rota Band 1B 10 doctors Band 1C)
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48-hr rotas Resident 24-Hour Partial
Shift(Band 1B)
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48-hr rotas Full shift (Band 1B with 9 doctors
upwards)
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Comparison NWD availability across different
working patterns - Non Resident
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Comparison NWD availability across different
working patterns - Resident
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New Deal for Junior Doctors The New Deal, agreed
in 1991 by representatives of the profession, NHS
Management and the government, is a package of
measures designed to improve the conditions under
which Junior Doctors work. One of the key
features is to place limits on the number of
hours of work. By 31 December 1996, the maximum
contracted hours for each type of working pattern
worked by junior doctors was agreed as 72
hours a week for on call rotas 64 hours a week
for partial shifts 56 hours a week for full
shifts
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Pay Banding
Band 1 under 48 hrs Band 2 over 48 hrs A,B,C
relates to the intensity of out of hours (OOH)
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New Deal Rest Requirements
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Pay Protection
Based on expectation of offer and
acceptance. Full guidance from NHS Employers
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Monitoring

• Twice yearly monitoring required
• Must receive over 75 of both doctors and duty
  return rate
• Must be representative of the normal working
  pattern
• Repeated in six weeks when returned invalid
• All new rotas should be monitored in the first
  six weeks
• Three stage banding protocol should be followed
• Ministerial returns
• Band 3 payments
• New Contract
• Living and working conditions

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Alternative solutions

• Service redesign
• New ways of working
• Advance roles
• Cross cover
• Collaborative solutions
• H_at_N 24/7 Solutions

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Further sources of information Trust EWTD
Teams Skills for Health (National Workforce
Project Pilots) DoH Deanery Royal
Colleges BMA
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Any Questions?