Reducing Medical Workload

  John Shand

Chairman North Glasgow University and NHS Hospitals Trust LNC

(john.shand@northglasgow.scot.nhs.uk)

Department of Radiology

Stobhill Hospital

133 Balornock Road

Glasgow

G21 3UW

It is now several years since what is potentially one of the most important pieces of European legislation for senior medical staff in hospitals was incorporated into UK law, yet its implementation throughout Scotland and the UK is patchy in the extreme. This legislation is the EC Directive on Working Time. It applies to all employees in the UK, not just Medical staff, and certainly has been acted upon outwith the NHS. For the Medical Profession a derogation1 was negotiated at the UK national level prior to devolution between the BMA and central government with respect to certain areas of its implementation in an attempt to minimise disruption to the service. Even then it has the power to not only control the workload of non-career grade hospital staff but also to act as a force for Senior Medical Staff expansion.

The reasons for its lack of implementation are multiple. In spite of it being legislation from Westminster with significant financial implications for the NHS there has been no extra funding made available for it. Another group that is delaying progress is NHS Management, they are tasked with implementing this legislation but find themselves in the position of either being unable to gauge its implications for service delivery or being aware of this, having no easy solution to cope with the effect on the service. Finally, the last group that has aided its non-implementation to date are ourselves, the senior medical staff. In general there is little awareness of the legislation and even in Trusts which have an agreement with management to allow it to be implemented the response rate for completion of monitoring diaries is disappointingly low. In North Glasgow for instance it is just over 20%. This reticence amongst the very staff it is designed to help creates problems for the Local Negotiating Committees attempting to instigate it in their Trusts’ and signals, hopefully wrongly, to management that there is little support for it within the Medical Profession.

There appears to be a lack of understanding leading to inaction in the Profession which is entirely understandable in an overworked and demoralised workforce, especially when confronted with what appears to be a mountain of complex paperwork, both to read and then to complete. The actual legislation can however be broken down into two reasonably sized packets. These are firstly a maximum of 48 hours work in the week and secondly a series of mandatory rest breaks. Both of these are assessed over a period of at least 4 weeks and preferably a full rota cycle if this is longer rather than constantly to reduce the administrative burden. This should be repeated every 26 weeks to ensure ongoing compliance.

The 48 hour maximum is for time actually worked, this doesn't include spells of on-call not actually working but does include phone calls related to work, being recalled to work and all time resident on-call. The full list of what is defined as work under the Act is allowed minor local variation; the North Glasgow definitions are listed in table 1. Items of special note include research and administration which will include preparation for committees, both of these are types of work that most if not all senior staff will do out with normal working hours and very probably at home due to the ever increasing volume of clinical work. Immediately on finding that a doctor is working in excess of an 48-hours during the monitoring period it is the responsibility of their Clinical Director (or other person who is responsible for their job plan) to discuss their job plan with them and take measures to reduce their total working hours. If this fails to satisfactorily reduce their working hours it is ultimately the responsibility of the Trust’s CEO to adjust the job plan or take whatever steps necssary to reduce their time worked. At a time when all surveys into consultant workload in the UK consistently demonstrate the average workload to be in excess of 50 hours per week, the potential reduction in work by senior medical staff can easily be seen.

The second half of the legislation refers to defined rest periods and it is this portion that the derogation affects. In the original legislation these rest periods were defined as follows:

These rest periods are to be uninterrupted and without the derogation should come into effect as soon as one of the defined periods of work has occurred. The potential implications of this for medical staff are immense. For example, if one is called out for an emergency in the middle of the night and returns home at 3.00 a.m. the legislation states that in the absence of the derogation the doctor should not commence work until 2.00 p.m.! This could well force the end of 24-hour periods of on-call and lead to shift work for senior medical staff.

  Due to the flexible nature of senior medical staff work patterns, especially with on-call rotas both the Government and BMA considered that the legislation, as it stood, would bring the NHS to a standstill and negotiated the derogation. This states that rather than taking the rest periods when they are due the amount of interrupted rest breaks should be monitored over the same period as the 48-hour working week.

These interruptions should then be summated and extrapolated from the monitoring period to a 26-week period. This is referred to as compensatory rest, which should be taken at a time when the doctor would otherwise be working. An example of this in a monitoring period of 4 weeks if the following rest periods were missed would be:

This would total 59 hours 40 minutes in 4 weeks and therefore extrapolate up to (59h 40m / 4 weeks) x 26 weeks. This equation produces an answer of 387 hours 50 minutes which is equivalent to just under 111 notional half days of 3.5 hours. This time off should then be taken over the next 26 weeks at a time, as previously stated, when the doctor would otherwise be working. This would result in approximately an extra 10 days off work. As with the 48-hour week it is the responsibility of the Trust to ensure that this time off is taken.

Even this brief summary above will appear complicated at first sight with data needing to be collected in half hour blocks continuously over several weeks, this being exacerbated because the 20 minute rest breaks do not fit neatly into this periodicity. They therefore require a separate section in the form. This leads to a daunting form to be completed daily over the monitoring period. The template of this form is part of the derogation and it is difficult to envisage a paper form that would be simpler and still allow recording of all the pertinent data. It should also be borne in mind that it is not only the completion of the forms that is difficult but also extraction of the data from them. We have certainly discussed within North Glasgow the development of a simplified form or even an electronic one. This may seem a minor issue but as an LNC Chairman I have had more queries and comments about the form than any other aspect of the legislation.

A fundamental point to stress is that this is Health and Safety legislation and designed to create a safer working environment for employees, both in terms of their own health and allowing them to perform their duties safely. As a result the time off accrued in compensatory rest cannot be exchanged for extra remuneration. Another issue is that of opting out, it is currently possible for employees to opt out of the 48 hour maximum although the onus is still on the Trust to monitor their hours of work. At a time when society is becoming increasingly litigious and lack of sleep leading to mistakes and accidents is a topical issue I believe that it would be exceedingly foolhardy to consider this option.

It is easy to understand why many Trust Managements are shirking their legal responsibilities when they would almost certainly lead to a requirement for a reduction in many consultants’ actual working hours. That should however not be an excuse for the current apathy and inaction amongst the senior medical staff within our hospitals. The first step must be for LNC’s to negotiate local implementation agreements, followed by all medical staff taking part in the monitoring and, with the support of the BMA, insist on the monitoring results being acted upon. Only then will we begin to see the reduction in senior medical staff workload and an expansion in the workforce to allow this.

Work force expansion is not an instantly available solution, especially in some specialities where there are not enough SpR’s to fill current vacancies let alone new ones. Other more lateral solutions must therefore be sought such as role enhancement for other staff groups in the health service and even more fundamentally and easier to implement the provision of adequate support staff to free up time to allow medical staff to perform core medical duties efficiently. How often have you heard of a senior manager without either a PA or a secretary? Yet lack of secretarial, nursing and paramedical support is a widespread problem that leads to inefficient working practises for medical staff. Provision of such extra staff would go someway to alleviating the current burden on senior medical staff and improve their working conditions in a manner that is achievable in less time than relying solely on consultant expansion.

In conclusion the EC Directive on Working Time with its attendant derogation is a powerful piece of legislation that has yet to be effectively implemented throughout Scotland. This is due to a combination of several factors, firstly politicians not fulfilling their moral responsibilities to fund legislation that they enact, secondly resistance from Trusts because of the ramifications on their performance figures and budgets and finally a general reticence on the part of senior medical staff. Control of  the last reason lies solely in our own hands, it cannot be left to the few who sit on LNC’s to progress this. They must have the active support of all whom they represent. Until this happens the law and local implementation agreements will simply lie in a corner gathering dust and be of no benefit to those that they are designed to help, namely ourselves.

Reference:

1 Guidance on Implementing the EC Directive on working time for senior hospital medical staff. CCSC March 1999

 Back to August Index