Time is fast running out to reduce the working hours of NCHDs in Ireland. NCHDs typically work 70 to 80 hours a week; the EU Working Time Directive requires these hours to be reduced to 58 per week by August 2004 (working towards a 48-hour week by 2009), and in parallel ensure that doctors receive specified rest and break periods.
In the 19 months available before the 2004 deadline, it is unlikely that the number of NCHDs or consultants can be substantially increased, even if the necessary funding was available from the Department of Health.
Similarly, while there is scope to reduce NCHD hours by transferring certain activities to other hospital staff groups, it will be difficult to reach agreement on such transfers and implement them by 2004. As such, the only realistic short-term mechanism for reducing NCHD working hours will be to radically change their work patterns.
Current work patterns:
The vast majority of NCHDs in Ireland continue to work traditional on-call rotas that require the doctors to work from 9am to 5pm Monday to Friday and to take it in turn to cover nights and weekends. The one exception is hospital A&E departments, where shift-working has been widely introduced.
In the past, on-call work patterns have been sustainable because the intensity of work out-of-hours was lower, doctors were willing to work very long hours and there was less awareness or concern about health and safety issues at work. But in the modern acute hospital environment, with a significant number of emergency admissions out-of-hours, on-call rotas that require a doctor to work very long shifts without proper rest are both unreasonable for doctors and unsafe for patients. Would any of us want ourselves or our families to be diagnosed or treated by a doctor who had not slept properly during the previous 32 hours?
What sort of change is required?
The EU Working Time Directive requires that by August 2004 NCHDs should work a maximum of 58 hours per week. It also requires doctors to have at least 11 hours of rest in any 24-hour period, plus 24 hours continuous rest a week (or 48 hours a fortnight), although there is provision to derogate these rest periods with local agreement, subject to equivalent periods of compensatory rest. For the purposes of the Working Time Directive, all of the time that doctors are required to spend on the hospital site is treated as working time regardless of whether or not the doctor is working or resting.
The implementation of the Working Time Directive will require fundamental changes to the work patterns of NCHDs. While it may be possible to retain on-call work patterns for “quieter” specialities such as psychiatry and dermatology where the out-of-hours workloads are typically lower, the vast majority of NCHDs will have to move to some form of shift-working, with doctors working shifts of between eight and 13 hours. This type of work pattern is now commonplace for junior doctors working in hospitals in Northern Ireland and Great Britain, and elsewhere in Europe.
The precise nature of shifts to be worked by NCHDs (length of shift, start/finish times, number of doctors working at any one time, handover arrangements, etc.) will vary according to local circumstances; for example, the intensity of the workload during normal hours and out-of-hours, the minimum level of cover required and the number of sites to be covered (hospitals, units, ward and clinics).
For those specialities, such as A&E and maternity units, where the workload is fairly constant during normal hours and out-of hours, shifts will need to be designed to ensure broadly the same number of doctors at all times during the day, night and weekends. For other specialities, where the bulk of workload occurs during the day-time (because of ward rounds, out-patient clinics, theatre sessions, etc.), shifts will need to be designed to ensure that the greater proportion of NCHDs are working during the day with fewer staff present out-of-hours.
Changes to work patterns are unlikely to be greeted with enthusiasm by NCHDs. Shift working is commonly seen as a threat to both their education and training, and the continuity of care provided to patients. However, the impact of shift-working on education and training can be minimised by ensuring that, as far as possible, doctors are present on the hospital site during the 9-5 period when the majority of the more “structured” training received by NCHDs occurs. Additionally, concerns in relation to continuity of care can be addressed by ensuring that adequate periods for the “handover” of patients are built into shift patterns.
Next steps:
The Irish health employers and NCHD representatives should agree a national framework for introducing new work patterns that will fully meet the 2004 requirements of the Working Time Directive, taking account of any derogation in relation to rest requirements.
This national framework should establish parameters (maximum shift length, maximum number of continuous working days, amount of rest to be achieved, minimum period between shifts, etc.) that can be used by Boards and NCHDs at a local level to agree new work patterns that best meet local circumstances. No doubt the current plans to increase consultant and NCHD numbers will continue to rumble on and, in parallel, efforts will be made to change the working practices of doctors and other hospital staff groups; but it is essential that new working patterns are introduced as a matter of urgency if the necessary reduction in NCHD hours is to be achieved by 2004.
