european working time directive and its impact on training medical education england independent...
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European Working Time Directive and its impact on training
Medical Education England Independent Enquiry
Chair
Professor Sir John Temple
June 2009
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European Working Time Directive (EWTD)
• Healthcare ;-
• is always supervised,
• and is usually delivered by
trained doctors
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What is a ‘Trained Doctor’?
• MB Ch B or equivalent X
• Membership/Fellowship of Royal College X
• Certificate of Completion of Training -CCT
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Concern about the ability of the NHS to deliver training in 48hr week
• Review the impact of the EWTD on the training of
– Dentists
– Doctors
– Healthcare Scientists
– Pharmacists
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Time for Training
A review of the impact of the European Working Time Directive on the quality of trainingProfessor Sir John Temple
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A comprehensive review process (Dec 2009 – April 2010)
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Evidence v Assertion
• Real evidence is lacking
• Repeated
– Assertion– Opinion or – information
was taken as a proxy for evidence
• Trainees perceptions were very important!
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EWTD impact
• is greatest when workload involves;-
– high emergency and/or
– out of hours cover
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High Quality Training can be delivered in 48 hours
• This is precluded when:
trainees have a major role in out of hours service
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EWTD impact
• Training & service are inextricably linked
• 48 hrs leads to > in shift working
• Shifts require > doctors to maintain cover
• Rota gaps > frequent
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Rota Gaps
Loss of elective training X2 Enforced rest
Generality Rota Gaps not Speciality (usually out of hours)
Limited learning Poorly supervised
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The effect of service on training
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Just how much training is provided in the current working week in the UK?
• In a 7 year training programme with 48hrs/week
• There are 15, 000 hours potentially available
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Who covers the nights?
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Findings – Consultant Expansion
Trainee increases have enabled retention of existing services and configurations
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Findings
• Consultant ways of working often support traditional training models
• Traditional service and training models waste learning opportunities
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Comparisons
Population Med students Residents
• UK 60 m 8,000 50,000
• Canada 30 m 3,500 10,000
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Make every moment count -1
• Training must be;-– Planned– Focused
Handovers must be;-
-effective
-safe
-supervised
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Make every moment count -2
• Accelerate learning by using:-
– Simulation– Role play– Video consultation– Other technologies
In controlled environments before practising on patients
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Skills Lab
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Use of simulation accelerates the acquisition of skills
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Effective implementation of EWTD results in
– Improved work/life balance
– Enhanced supervision
– Reduced loss of daytime elective training
– Improved handovers
This produces safer patient care
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EWTD can be a catalyst for change
• Service reconfiguration
• Hospital at Night
• Consultant & Trainee contract flexibility
• Training simulation and new technologies
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The case for change
• Reliance on trainee doctors to deliver a 24/7 service has to change
• Increasing – hours/length of training now will simply maintain the present system
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Recommendations - 1
• Implement a consultant delivered service
• Service delivery must explicitly support training
• Learning must continue to be service based
• Make every moment count
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Consultant delivered service
C
T
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Consultant delivered service (CDS)
Readily available Graded supervision
Resident CDSOnly when service load demands)
Viable sized teams No other duties (when on call)
Service re-organisation
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Consultant delivered service
• Lead to closer supervision by consultants;
– Increase learning opportunities
– Improve, diagnosis & treatment
– Enhance patient safety
And reduced patient costs
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What is a fully Trained Doctor?
• Completed a training programme
• Certificate of Completion of Training (CCT)
• Appointed to a Consultant position in NHS
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Consultant delivered service
– Trainee programme 7yrs
– Consultant 25-30yrs
Consultant:trainee alignment
– Consultant : Trainee 3:1
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Consultant delivered service
Action
> Consultants < Trainees
Service Teaching
Not all consultants or services will have trainees
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Consultant delivered service
• 24 hr presence or ready availability for direct patient care
• More flexible working of the consultant contract
• Multi disciplinary Team - not ‘Firm’ approach
• Mentoring of all consultants
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Recommendations - 2,3 & 4
• Some service redesign is necessary
• Recognise, develop and reward training
• Training excellence requires regular planning and monitoring
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Healthcare ;-
• is always supervised,
• and is usually delivered by
trained doctors
![Page 40: European Working Time Directive and its impact on training Medical Education England Independent Enquiry Chair Professor Sir John Temple June 2009](https://reader030.vdocuments.net/reader030/viewer/2022032607/56649ec85503460f94bd568a/html5/thumbnails/40.jpg)
High quality training can be delivered in 48hrs
• To achieve this the NHS needs:
– Fundamental changes to training & service– Clear Leadership– An explicit implementation plan
Action is needed now
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• We must produce
Competent, confident and safe doctors who will embrace life long learning.
‘Training today is patient safety for the next 25-30 years’
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EWTD – the fine points
• Introduced 1998
• Full implementation – 48 hrs – 1/8/09
• Working time includes – on the job training on call at the workplace
• Junior doctors are not classed as night workers
• Simap & Jaegar rulings
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Time for Training
A review of the impact of the European Working Time Directive on the quality of trainingProfessor Sir John Temple