The ongoing NCHD dispute threatens to escalate into an all-out national strike unless the parties concerned – the NCHDs and the health service employers – can reach agreement. At the centre of the dispute are the efforts by two health boards to change the working patterns of NCHDs with a view to reducing their working-hours, in line with the requirements of the EU Working Time Directive. The Directive places a legal requirement on member-states to reduce the working-hours of doctors in training to 58 hours per week by 2004 and 48 hours per week by 2009. NCHDs in Ireland typically work 70 to 80 hours a week.
The NCHDs and the IMO have strongly resisted the health boards’ proposed changes on the grounds that the new working patterns will reduce the amount of time that NCHDs spend in hospital during normal working hours, ie, nine am to five pm, Monday to Thursday and nine am to four pm on Friday. The doctors argue that the majority of their training takes place during these “normal” working-hours and, as such, any move away from these hours will reduce the amount of training they receive.
It is certainly true that the majority of the more “structured” training received by NCHDs occurs during the nine-to-five period when, for example, formal teaching sessions are held and doctors have the opportunity to assist with consultant ward rounds and out-patient clinics. It is obviously important that NCHD involvement in these activities is maximised. However, any inference that all NCHDs are currently present during normal nine-to-five working-hours would be incorrect: some NCHDs already receive time-off on the weekday after their night on-call (either a half-day or the whole day-off).
Furthermore, the very nature of the NCHD role means that they are continually exposed to new opportunities to apply and develop their skills, whether working in a hospital ward, in a theatre, or in the accident and emergency department. Most of the training received by NCHDs is “on-the-job”. Since hospitals provide a 24-hour service, it follows that NCHDs will be exposed to training opportunities during both normal hours and out-of-hours periods. An emergency can happen at any time of the day: a person is as likely to require treatment for a major stroke or require emergency surgery at 11pm as much as at 11am. Correspondingly, there are round-the-clock opportunities for NCHD involvement in patient diagnosis, patient care and learning.
What needs to be done:
To reduce the working-hours of NCHDs to 58 hours per week by the 2004, as required by the EU Working Time Directive (a reduction of as much as 20 per cent to 25 per cent) will require significant changes to the role and work patterns of NCHDs.
The traditional role of many NCHDs – particularly more junior staff – has required them to spend a considerable amount of their time carrying out activities that are inappropriate to their role as doctors.
The need for NCHDs to work a reduced number of hours makes it important that when they are working, they spend as much time as possible on activities that are contributing to their education and training.
To this end, health boards and NCHDs should work together to identify any inappropriate activities currently being undertaken by NCHDs, with a view to ending these activities altogether or transferring them to other staff, as appropriate.
Examples of activities that are inappropriate for doctors to undertake on a routine basis include additions to IVs, male catheterisation, ECGs, routine phlebotomies and administrative support activities such as bed-booking and looking for X-rays or lab results. These activities can be undertaken by other care staff (nurses, midwives, ECG technicians, phlebotomists) or administrators (bed co-ordinators, ward clerks), as appropriate.
Inevitably, however, the extent to which working-hours must be reduced will require some reduction in the number of NCHDs working in hospitals at particular times of the day and night. Health boards and NCHDs must, therefore, work together to identify how such changes can be made with the least impact on NCHD education and training and the delivery of patient services. As far as possible, efforts should be made to ensure that NCHDs are present during the nine-to-five period, but the need to maintain adequate levels of out-of-hours cover means that there will almost certainly have to be some reduction in the level of day-time NCHD cover at some hospitals.
