EU Working Time Directive (NHS)

Charlotte Leslie Excerpts

Thursday 26th April 2012 Westminster Hall

[Charlotte Leslie (Bristol North West) (Con)]

It is a pleasure, Mr Brady, to serve under your chairmanship. We have heard a lot during the past few months about structural reform of the NHS, but today I want to concentrate on something that underlies the success of any structural reform now or in future: safeguarding the expertise and professionalism of our medical work force, and our future consultants. I think we all agree that the NHS is not a system; it is the people who work within it. The expertise, dedication and professionalism of our clinical staff are what give the NHS its tremendous robustness to adapt to and, dare I say, withstand political restructuring. That is largely what has enabled it to meet the ever-increasing demand being placed on it by an ageing population, rising expectations, and all the other factors that we so often talk about. If the NHS loses that clinical expertise and professionalism, it will no longer exist as we know it. Under our watch, doctors are warning with increasing urgency that that professionalism and expertise is being severely eroded, and the expertise of our future consultants is being jeopardised, so patient care is being compromised daily.

What is having such a damaging effect on the future of our NHS? With the previous Government’s very badly structured new deal, the threat to the NHS is the European 48-hour working time directive. It was introduced with the reasonable aim of putting an end to junior doctors having to work 100 hours or more a week. Obviously, that was bad for junior doctors, and dangerous for patients. No one wants to be operated on by someone who has had a ridiculous lack of sleep. We do not want to return to those bad old days, but the effects of this well-meaning directive are devastating, and it would be utterly wrong and immoral to dismiss the arguments about the 48-hour working time directive simply by presenting a simplistic either/or argument: either a 48-hour working time directive, or a return to 100-hour weeks. That argument would be misleading, it has no strength, and it is wrong.

Doctors have been making the case strongly, and trying to get the political class to hear. They have warned that the working time directive is devastating the NHS in three ways. First, on doctor training, it is eroding the professional ethos that upholds the NHS, and beginning to replace it with a clock on, clock off culture. New generations of junior doctors will know only that. They will never know the old ethos that sustained our NHS. Secondly, the safety of patients—our constituents—is being seriously jeopardised daily. Thirdly, I am sure the Minister appreciates that the financial cost is absolutely massive. I will deal with those three issues in turn, before concluding on the final, biggest blow, which is that the directive does not achieve its aim of a better work-life balance for doctors, and in some cases it makes matters worse.

The previous Government estimated that the introduction of the European working time directive, given the existing new deal limitation of a 56-hour working week for doctors, would be the equivalent of taking 4,000 doctors out of circulation. The Royal College of Surgeons estimated the loss of surgical time per month to be 400,000 hours. To put that into perspective, that is equivalent to 45 years of surgical time per month being lost to the NHS. That means that doctor training is limited in two ways.

The first is simply the amount of time that doctors have to train, and we can all appreciate that. It is important to appreciate that the quality of the training that doctors can access has also been severely eroded. Hospital trusts have had to adopt a shift rota system to incorporate the working time directive. Under the old on-call system of working, a medical specialist—an expert—was always on call in case a problem arose, or there was an emergency out of hours. A specialist was always on hand to help any doctor on duty, but with the new system, that is not always the case, so patient safety is jeopardised.

Doctor training is also jeopardised. Trainees complain that they do not get the training they used to receive because they are increasingly meeting the demands of staffing hospitals out of hours and at night without the training and accompaniment of a consultant. The team-working relationship between trainee and consultant is what is so valuable to trainees, and its breakdown is detrimental to the quality of and amount of time for training. The Association of Surgeons in Training reported that two thirds of trainees believed that their training had seriously deteriorated since the introduction of the directive. Sadly, most doctors report that they break the rules—I will return to that—to access the sort of training they want. We are dealing with a work force that values clinical excellence and the welfare of their patients.

My second point is about the welfare of patients. From the patient’s point of view, the directive massively damages continuity of care. Under the shift system, we are seeing a clock on, clock off system, with a dramatically increased number of handovers between doctors. That is clinically risky, because handovers are when vital information may be missed, and under the directive those handovers take place under increasing time pressure. As with Chinese whispers, messages are distorted down the line.

[Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)]

My hon. Friend makes an excellent point, but is it not also the case that medicine is traditionally about providing continuity of care for patients through having a dedicated team of doctors looking after them? If we move towards a clock on, clock off culture, as we now are, and a shift-based job, continuity of care will be lost, patient care will be damaged, and bad things will happen to patients.

[Charlotte Leslie]

My hon. Friend makes an extremely good point, and I know that he has first-hand experience in this area.

Professional expertise and intuition, not looking at a list of tick boxes, enables doctors to spot that something is wrong with a patient. If doctors are not able to make a subtle comparison between how a patient was yesterday and how they are today, their intuition and expertise will be undermined. We have all seen constituents who have felt that they have been subject to an endless conveyor belt of doctors, and have been made to feel like a product on a conveyor belt instead of the focus of a dedicated team looking after them. The move to treating patients as products on a conveyor belt is worrying, and undermines the very good ethos of our NHS. Clinicians back that up. One third of surgeons in a recent survey said that handovers had been inadequate and, worryingly, the Royal College of Physicians found that three in 10 thought that their hospitals’ ability to deliver continuity of care was poor or worse. A similar survey of GPs found that one third thought that their hospitals’ treatment was dangerous. I cannot emphasise enough the urgency of the matter.

[Mr Robin Walker (Worcester) (Con)]

To add to the chorus of support, one of my constituents is John Black, a famous surgeon from Worcester, and past president of the Royal College of Surgeons, who told me that if there was one thing the Government could do for the NHS, it would be to take up this issue and get it sorted out. Does my hon. Friend agree that the Government must take up the cudgels with Europe and fight for our interests?

[Charlotte Leslie]

My hon. Friend anticipates a point that I will come to later. I pay tribute to the work of John Black and others on this issue. If there was only one target that the NHS should enshrine, it is continuity of care, because after that so many things follow.

European Court of Justice rulings—I do not want to be too technical, but they are the SiMAP and Jaeger rulings—have caused tremendous problems for the profession. First, inactive on-call work is required to be counted as working time. Therefore, if a doctor is on call but inactive and perhaps sleeping on the premises, it is counted as on-call time, which makes life very difficult for hospital trusts organising rotas and getting the time available. Secondly, if a doctor overstays their allocated shift, perhaps because they are about to hand over, but have to stay on for an extra hour, perhaps because a patient has had a cardiac arrest, they are required to take compensatory rest to make up for that immediately afterwards. If that doctor has a clinic some time the next day, they will have to take an hour of rest time, cancelling that clinic, because the European Court of Justice dictates that. Potentially, patients who have turned up at hospital and are ready and prepared for surgery will have their clinic cancelled because the Court ruling says that the doctor must be forced to take rest. That is obviously a tremendous inconvenience for patients, beyond continuity of care, and a nightmare for the hospitals trying to make accommodations.

[James Wharton (Stockton South) (Con)]

I congratulate my hon. Friend on securing this important debate. She has spoken eloquently about the challenges that the rulings cause for the running of hospitals, and the problems that they cause in the care of patients. Does she agree that treating doctors in such a way, commoditising the patients they work with and clocking their work on and off damages their ability to do their job professionally, which affects their health too?

[Charlotte Leslie]

Absolutely. My hon. Friend makes an extremely good point. An interesting point that I shall come to later is that the Royal College of Physicians reports that sickness rates have soared because of the stress on clinicians as a result of not being able to perform their duties with the professional excellence that they espouse. The directive has a detrimental effect on the professional ethos of the NHS, and on the individuals whom it was designed to help.

[Chris Heaton-Harris (Daventry) (Con)]

My hon. Friend is doing a fantastic job of articulating the problems that the working time directive has brought to the NHS. On the question of the Jaeger ruling at the European Court of Justice, is my hon. Friend aware that the Republic of Ireland has had problems, and has tried to exempt training from its definition of work, so that trainee doctors fall outside the scope of the directive? In the Netherlands, trainee doctors are apparently classed as autonomous workers: the Netherlands, too, tries to sideline the directive. Across Europe, it is causing problems in health services.

[Charlotte Leslie]

I know that my hon. Friend has done a tremendous amount of work in this area. The ways in which other countries get round the directive will be the conclusion to my speech. The Minister has a choice whether to prioritise political process in Europe or patients. Will we put everything into finding a way to give patients the care, and the professions the flexibility and respect, that they deserve? I thank my hon. Friend the Member for Daventry (Chris Heaton-Harris) for anticipating that point.

[Andrew Bridgen (North West Leicestershire) (Con)]

I congratulate my hon. Friend on securing this important debate. We will all be aware that it has recently been reported in the media that the mortality rates for someone unfortunate enough to be taken into hospital on a Friday night, Saturday or Sunday are about 20% worse. Does my hon. Friend think that the working time directive is exacerbating the situation and preventing us from dealing with the problem of continuity of care?

[Charlotte Leslie]

I suspect that that is a problem in hospitals in colleagues’ constituencies, and I look forward to hearing about those. It is not just politicians in the Houses of Parliament who say these things, but, crucially, clinicians on the ground, whose prime concern is looking after patients. I certainly agree with my hon. Friend’s point.

One area in which the restrictions of the working time directive become apparent is in the case of a flu pandemic. The guide to the implications of the European working time directive for doctors in training makes it clear that even in a flu pandemic there are no exemptions from, and there is no flexibility about, the 48-hour rule. It is true that individuals can opt out of the directive, but they are still limited by the previous Government’s new deal to working 56 hours a week. However, there is no mechanism to compel doctors to opt out of the 48-hour working time directive.

[Matthew Hancock (West Suffolk) (Con)]

I am grateful to my hon. Friend for making such a powerful case. Can she explain why this is an EU issue at all, since the directive is meant to engender a single market, but the NHS is a British-only institution?

[Charlotte Leslie]

My hon. Friend makes an extremely good point. That issue was contested to some extent when the directive was first introduced, but the previous Government saw it as a health and safety issue, and therefore the NHS was included in it. There are many reasons why we need not be in this position. There are many aspects of the negotiation that are deeply regrettable, and I agree with my hon. Friend. Although this is going over old ground, it is vital to look at that to find out how to get out of our current situation and secure patient care.

[Mr David Nuttall (Bury North) (Con)]

My hon. Friend will be aware that maternity units have closed in many constituencies, including mine. I was told that one reason why the health authority wanted to reconfigure the unit, as it put it, was the impact of the working time directive. Does she find that impact of a European regulation on my constituents in Bury North as shocking as I do?

[Charlotte Leslie]

I find it shocking and outrageous that that is allowed to happen. Its importance cannot be overestimated. Lives are being put at risk because of Brussels bureaucracy that does not even begin to protect the workers whom it says that it is designed to protect. This is one of the most important issues in the NHS, and I urge the Minister to do everything possible to work with colleagues in the Department for Business, Innovation and Skills to sort it out.

To return to the point about the flu pandemic, many people say that things will be okay because the 48-hour week is an average that can be measured over six months; so if there is a pandemic everything will be fine, because the doctors can sort it out and go back to normal afterwards. Well, if the pandemic were to last more than six months, I do not know where that would leave us. If it were to last less than six months, we would not have any doctors able legally to perform routine functions. That demonstrates how rigid, bureaucratic, badly thought-through and frankly dangerous the directive is.

The cost, however, is not only human: it is financial, and it is massive. Colleagues are concerned about the closure of their constituency hospitals and the ability of those hospitals to find coverage. Hospitals are floundering and struggling to find staff for an ever-increasing demand on the NHS. Let us not forget that the restriction on staff is happening at a time of unprecedented demand on our health system. Stafford hospital closed its accident and emergency department in the evening because it could not find cover. Other hospitals are taking other measures and spending exorbitant amounts of money on temporary staff to fill the gaps. Many colleagues will have read about the £20,000-a-week temporary doctor who was brought in to fill the gaps. Hon. Members will be shocked to learn that a staggering £2 billion has been spent in the past two years on temporary staff in the NHS. If we think about the financial challenges that the country faces and where else that £2 billion could have been better spent, that figure demonstrates how crucial the issue is. One hospital trust spent £24 million on temporary staff because of the staffing problems caused by the directive.

As I have hinted, the grim irony is that, for all the contortions and scheduling arrangements that hospitals, doctors and trusts go through to accommodate the directive, it is not even doing what it was supposed to do and make the work-life balance for doctors better. I received an e-mail from a junior doctor who is soon to get married and wants to spend time with his fiancée and plan his wedding, and who is frantic, not only about the erosion of his training and his future professionalism, but also about the destructive influence of the directive on his home life and his work-life balance. He writes:

“The directive certainly hasn’t made any impact on quality of life. Having worked 60-70 hours a week, now doing 48 hours, I am no less tired...the stated aims of improving work life balance and improving training are farcical.”

Then he goes on to talk about the realities that junior doctors face. He says:

“There is simply not enough time in the 48 hour week to get trained, particularly in the craft specialities, so we all go in on our days off. If we don’t, we don’t get trained and it is us, our careers, and ultimately the patients who suffer. Training used to happen in our official working hours, now we work just as hard, but get trained in our time off, and don’t get paid.”

And he is not alone. The Association of Surgeons in Training reported similar exhaustion because of the directive, and the Royal College of Physicians, as I have already mentioned, reported soaring sick leave since it was introduced.

I have spoken to junior doctors who report worrying signs of things to come. Given the contortions of shift working under the directive and the changes to on-call working time, junior doctors increasingly report that they are reluctant to specialise in disciplines that have more arduous on-call demands and require presence at the hospital, such as acute medicine, general surgery, obstetrics, gynaecology and anaesthesia. An unofficial straw poll of senior house officers in one city showed that they nearly all did everything they could to avoid being on the acute register because that was such a nightmare. They just thought, “Why would we?”

Statistics showing the number of applications and the number of positions available in those disciplines suggest that junior doctors who report such trends are not wrong. We are beginning to see our most talented doctors moving away from the disciplines that put the most stress on their work-life balance because—let me stress this—of the directive. When making lifestyle choices, doctors are looking at those specialist disciplines and thinking, “Why would I go into that?” which is extremely worrying for the future of our NHS provision. We have to stop that trend before it becomes more cemented.

[Mr William Cash (Stone) (Con)]

My hon. Friend is making a most compelling speech on a matter of extremely great importance. Does she recognise the problem that everything that she has said stems from a system that is based on treaties and backed up by the European Court of Justice? Therefore, we cannot make changes unless we renegotiate the treaties. In a matter of such importance, will the Minister make the necessary adjustments to achieve the objectives sought by my hon. Friend and ensure that we get a result?

[Charlotte Leslie]

I thank my hon. Friend. He has done a tremendous amount of work in this area, and I bow to his expertise. I see the solution as twofold and two-speed. First, we must ask why we are in this situation, and we must look at the treaties. Open Europe has suggested an interesting double-lock mechanism for negotiating our way out of what was the social chapter and creating a situation in which we are not bound by the rulings of the European Court of Justice. Those are big, radical steps and will take time, but it is something that we should look at.

This issue is of great importance on a daily basis. Each year that passes, a new generation of doctors enters a system that is systematically undermining the most important element of our NHS. Because issues to do with Europe are so tangled, difficult and frustrating, we need to look at more practical and instantaneous ways of getting around the directive with which we are inflicted. I take my hon. Friend’s point, but a two-speed approach is vital because of the issue’s importance.

[Andrew Bridgen]

My hon. Friend said something about medical professionals going to work on days when, under the working time directive, they are legally supposed to be at home or on holiday. Is she as concerned as I am that that could raise serious problems and create confusion and grey areas about professional negligence for medical professionals who are supposed to be on holiday but are actually working in the hospital? Will the Minister explain where they would stand on that matter for insurance purposes?

[Charlotte Leslie]

My hon. Friend raises a good point that will be of great interest as things progress. In a culture in which litigation against the NHS is becoming more and more common, what will happen if patients feel that their safety has been compromised because of the lack of training received by their doctors? The European directive raises all sorts of issues about patients’ rightful expectations of those who treat them.

[Neil Parish (Tiverton and Honiton) (Con)]

I thank my hon. Friend for the excellent speech that she is delivering. This, of course, is the social chapter that Tony Blair signed up to in 1997 kicking in, and I suggest that the Government might want to get us out of that legislation. I feel that irrespective of what length of time doctors might work, it is down to them to negotiate that with hospitals, rather than have it imposed by a directive. That is the biggest problem; things must be done by negotiation and not by directive.

[Charlotte Leslie]

Again, I agree with my hon. Friend. One of the most destructive things is that the directive puts a cap on excellence. If people want to put in extra time to become excellent in their field and be a world-leading expert, they will not be allowed to because someone in Brussels and the new deal says no. That worries me tremendously in terms of our competitiveness with the rest of the world. We have some of the world’s leading experts in many fields of medicine, but America and Australia do not have such restrictions and they will pull away because we simply will not see talent coming through. Worse than that, a country that says to bright, talented young people who are going into a service occupation to serve the public, “We are going to put a cap on your endeavour” is a country of which none of us would want to be part. The precedent that that sets is absolutely diabolical.

Let me come to an issue that is much more difficult. It is easy to sit and point to problems, but some things are much more difficult, especially, as hon. Members have said, when they involve the dreaded E-word—Europe. What can we do? There is no doubt that there is a massive consensus across the medical profession that something needs to be done. The Royal College of Surgeons, the Royal College of Physicians, the NHS Confederation and NHS employers all say that they have massive concerns about the country’s health service. However, an interesting omission from that list is the British Medical Association, which seems absolutely content. It wants to keep the opt-out, but it seems absolutely content with the SiMAP and Jaeger rules that are playing havoc with our hospitals and with situations that are driving many junior doctors to despair and sick notes. I guess that it negotiated the new deal, but it is odd and disappointing that, on this issue, it seems so unrepresentative of so many fields of the profession.

Ministers have said that they are working urgently with Europe for a solution. I have no doubt that that is true, and I appreciate the complexity of the situation. However, I am beginning to think that waiting for a solution to come out of Europe is like waiting for Godot. As hon. Members will know, this debate has been revolving around the European Commission and the European Parliament for almost a decade. It has come back again, and people are still trying to agree on what they are going to discuss. They have until September this year to agree that, but given past history, I have no faith whatsoever that an agreement is on the cards, let alone any results, and the precedent that has been set is not encouraging. While that farce has been going on in Europe, the clock has been ticking every day. Every day, patients’ lives are put at risk; every year, new generations of doctors enter a system that does not serve them, their patients, or the country.

What can we do? First, we should look at what we want. As I have said, no one wants a return to the bad old days when junior doctors were working ridiculous hours and were too tired to function, and patient safety was put at risk. The professions say that they want flexibility. For example, the Royal College of Surgeons has said that a working week of up to 65 hours, with a bit of flexibility, would be extremely good, and that will differ from discipline to discipline. Anaesthetists may want something slightly different from the surgeons, but the point is that our professionals know what they are talking about and what they are doing, and they deserve the flexibility to drive their services as they see fit. The Government have taken seriously the agenda to put professionals in the driving seat. We want flexibility, not arbitrary limits on times.

What can we do? My hon. Friend the Member for Daventry (Chris Heaton-Harris) has already mentioned what some other countries do. In the Netherlands, for example, doctors are classed as autonomous workers, because they earn more than three times the average wage in that country. We can look at such a classification, although that might be a complicated solution.

[Caroline Dinenage (Gosport) (Con)]

Let me add my voice to the chorus of praise for my hon. Friend who has secured this debate. A number of medical professionals from my constituency have raised this issue, and some of them feel so strongly about it that they are present in Westminster Hall today. Other services such as the armed forces, the police and even deep-sea fishermen have been granted an exemption from the working time directive. Does my hon. Friend think that the Government should issue an exemption for medical professionals?

[Charlotte Leslie]

My hon. Friend makes a good point, although we do not want to return to ancient history when things were conducted in a regrettable way. It is of great regret that, when trade unions and the BMA were negotiating with the then Government about how to implement the directive, the option of a sectoral opt-out was removed. Other hon. Members will have greater expertise on this matter, but I have been looking at the ways that a sectoral opt-out can now be negotiated. However, because time has passed since the original negotiation, it is now a lot more difficult to go for a sectoral opt-out. None the less, the common sense of the comment is apparent to everyone. It is a disgrace that the previous Government oversaw the implementation of one of the single biggest damaging factors to our NHS, as well as supplanting it with the new deal. We should make more of that because it has eroded so much confidence in our profession and it will have ramifications for a long time to come.

Spain applies the 48-hour limit to contracts and not to individuals, which is something that we could consider. In Ireland, training is not counted as work time. I am sure that there are lawyers all over the place who will say, “We can’t do that.” They will give all sorts of reasons why not. Again, I say to the Minister that this is a question of priorities. There are always procedural reasons why not, but if we consider what is at issue, the stakes could not be higher.

In conclusion, I urge the Minister not only to continue his energetic negotiations in Europe with colleagues in the Department for Business, Innovation and Skills, but to look again carefully at what practical measures we can take to alleviate and mitigate the effects of this absolutely disastrous directive on our NHS.

--- Later in debate ---

[Andrea Leadsom]

All I am saying is that, under the Lisbon treaty, member states that do not like certain legislation have the opportunity to club together and to propose that the European Commission look at it for possible deletion or significant amendment. That happened with the working time directive at two points in the past, in 2004 and 2010, but the attempts to amend it came to naught. The great tragedy is that with 27 member states there is simply a Chinese whispers effect. Someone says, “This is ridiculous, it is harming our national health service”; everyone agrees, “Yes, it’s ridiculous”, and therefore an amendment is proposed; but by the time it has gone around 27 member states, it is completely lost and gets nowhere. That is the fundamental problem with negotiating amendments.

My original point was about the importance of the time line of the working time directive. In 1990, the European Commission tabled the proposal for the working time directive as a health and safety measure. In November 1993 the UK was outvoted 11 to one at the European Council negotiations. The European Commission stated that the working time directive was

“a practical contribution towards creating the social dimension of the internal market”—

it was all about health and safety for employees, and employees in the real economy overworking; it was not intended to have the profound impact it has had on the national health service. David Hunt, who was Employment Secretary under the then Conservative Government, said that he would fight the legislation and not accept it. He tried hard, by going to the European Court of Justice to challenge the legal basis of the directive as health and safety legislation, but the UK was outvoted.

In 1996 the ECJ ruled against the UK, and Labour implemented the working time directive in 1998. The directive requires a maximum working week of 48 hours, a rest period of 11 consecutive hours a day, a rest break when the day is longer than six hours and a minimum of one rest day per week, as well as the statutory right to four weeks’ holiday. Such a list of requirements highlights the directive’s complete inflexibility; it clearly cannot be applied to absolutely every type of worker in our economy. In the end, the European Union had to admit that there were certain exceptions, which is why in some countries trainee doctors are treated as autonomous—in other words, self-employed. That is used as a means to get round the rules, because it is never going to be possible to enforce that kind of rigidity on people who are self-employed. There are all sorts of unintended consequences from a prescriptive and damaging set of rules.

In his response, will the Minister confirm whether the NHS has caused some of those problems—not necessarily deliberately—by offering contracts to doctors and junior doctors that are subject to a maximum of 48 hours? We should remember that the NHS is not allowed to invite new employees to opt out of the 48-hour working week at the same time as they sign their contract, because of fears of coercion. Does the Minister have a view about whether the NHS has created part of the problem by telling junior doctors and other health workers in their contracts that they will be paid for a 48-hour week, and then inviting them to opt out at a later date? There is a wealth of evidence to suggest that many doctors are working hours that are unpaid because their contract allows them to be paid for only 48 hours a week. Perhaps the Minister will comment on that in his response.

[Charlotte Leslie]

Does my hon. Friend agree that there are inconsistencies across the landscape? When I applied to work for the BBC, although I cannot remember exactly how it was worded in my contract, I was left under no illusion that if I wanted a job, I was to tick the little box that signed me out of that 48 hours business.

[Andrea Leadsom]

That is very interesting. Clearly, my hon. Friend’s contractual employment was not correct because she should not have been asked that question at the same time as signing the contract.

I would like to cite a case study of a junior doctor who was employed under the working time directive in foundation training between 2009 and 2011. This is his story:

“When I was on my surgical placement as part of my training, we were told by the hospital to take a mandatory ‘zero hours’ day off every week, as we were working 8 am to 6 pm on the other weekdays, as well as some longer on-call days and on-call weekends at times. The purpose was to keep our average working week within the 48-hour limit.”

That is utterly bizarre.

“We rotated who took the day off among our team, but this meant that on any particular day only one or two doctors would know the patients who had been admitted the day before. However, those particular doctors might not be there the next day, so would have to hand over patient information to a colleague. Unsurprisingly, much information was ‘lost in translation’. Trainee doctors would also not know which registrar, or even consultant, to expect on any particular day, due to the irregular working patterns of these people also caused by the limits on working time.

Furthermore, patients no longer knew who would see them on the ward round. The effect was poor patient experience, as patients were unable to build a rapport with individual doctors. People would be very frustrated that the doctors seeing them did not know what the same medical team had planned/achieved the day before.

There is also much less time for on-the-job training for junior doctors. This was compounded by the fact that we often had to cover for other trainees who were rostered off due to the working time directive, missing our regular teaching sessions. Lack of training time has made it difficult for us to establish a rapport with our seniors, and gain adequate support in terms of mentorship and career advice. In fact, trainee doctors no longer feel that we ‘belong’ to a team, given the new shift patterns that have broken up teams of trainee doctors and their seniors. Morale is certainly lower and junior doctor sickness rates much higher. This is a negative spiral—more doctors off means that when you do turn up, your working day is more hectic and stressful, and you are much more likely to fall ill and take time off yourself.

Diary carding exercises (whereby doctors record the actual hours they work) have shown almost universally high rates of non-compliance with the working time directive. During my general medicine attachment in training, I ended up working 1.5 to to 2 extra hours (unpaid) per day and was consistently non-compliant…Doctors that do opt out of the 48-hour limit on the working week are sometimes not sure whether they will be remunerated appropriately for their time.”

That is interesting and highlights some of the problems faced by doctors who are trying to do the right thing by their patients. Of course, this is not only about doctors but about patients. My right hon. Friend the Minister will be aware of two recent cases where coroners have recorded problems associated with the working time directive. They said that it impacted on the ability of doctors to understand what was going on with patients, and that was one of the factors that caused the untimely death of a patient. The other case involved a patient undergoing a routine operation.

Let me quickly turn to the solutions.

--- Later in debate ---

[Chris Skidmore (Kingswood) (Con)]

As a member of the Select Committee on Health, I am very interested in this debate. I have learned a lot from the engaging contributions of all hon. Members who have spoken.

I want first to acknowledge the hard work of my hon. Friend the Member for Bristol North West (Charlotte Leslie), and not only for this debate. I want to put on the record the fact that she has campaigned on the matter for nearly two years. She has brought it up in recess Adjournment debates, Health questions, Prime Minister’s questions, and a ten-minute rule Bill—the NHS Acute Medical and Surgical Services (Working Time Directive) Bill. She has not let the issue go, and I think it is important to put that on the record because, without all her work over the past two years, we would not have achieved this Back-Bench debate today, which is extremely important, and the final Backbench Business Committee debate of the Session—and very apt it is too.

Following my hon. Friend’s two-year campaign, the exact financial cost and burden on the NHS caused by the directive is becoming clear. On 18 March, The Sunday Telegraph published a freedom of information request about the cost, and some of the figures have been read out, but I want to read out a few more to place them on the record. Of the hospital trusts that provided figures, 80% admitted spending more than £1,000 per shift on medical cover as a result of the EU working time directive. In total, £2 billion has been spent on that since 2009, which is roughly equivalent to the wages of 48,000 nurses or 33,000 junior doctors.

We have talked about inequalities. It is worrying that some trusts are clearly suffering more than others, and some are in extreme financial difficulties. Yet North Cumbria University Hospitals Trust spent £20,000 on hiring a surgeon for one single week. Mid Staffordshire NHS Foundation Trust—my hon. Friend the Member for Stafford (Jeremy Lefroy) referred to this—spent £5,667 for a doctor for just one 24-hour shift in a casualty unit. The Christie NHS Foundation Trust in Manchester spent £11,000 on six days’ cover for a haematology consultant. Scunthorpe general hospital offered £100 an hour for one month’s work in a temporary post. Princess Alexandra Hospital NHS Trust in Essex paid more than £2,000 for a locum doctor to work a 12.5 hour shift last October.

I could go on, but I want to come back to that £2 billion in two years, and to relate it to the Nicholson challenge, which is a cross-party issue, of saving £20 billion to reinvest back into front-line services. The challenge was set in 2009 by the previous Government to take place over three years. As a result of the comprehensive spending review, that has now been extended to four years. No MP can claim that that is a cut by one Government or another, although some MPs have tried to. It is a cross-party approach, and we in the Chamber are responsible and understand that if the NHS is to remain free at the point of use, regardless of ability to pay, we need to make savings and to reinvest them into front-line care.

The coalition Government have already done a fantastic job in making savings of about £7.5 billion on the way to the £20 billion figure. But the reality is that, if this £1 billion a year cost to the EU working time directive remains, that will be a £4 billion cost over the period of the comprehensive spending review. Therefore an extra £4 billion will need to be found in efficiency savings. We are moving from a 20% efficiency gain, therefore, to almost a 25% one. [Interruption.] It appears that the Minister disagrees, but it is just a back-of-an-envelope calculation.

[Charlotte Leslie]

My hon. Friend is contextualising this debate in an important way, in respect of wider finances and the Nicholson review. Reverting to the question of evidence, does he agree that simple figures, such as these, on the cost of a directive that has been introduced are also evidence? The first-hand reports of clinicians on the ground are perhaps more reliable than the evidence gathered from sources that might not always be willing to tell the truth about the situation, for fear of not meeting compliance targets.

[Chris Skidmore]

Absolutely. On the figures I mentioned, only 34 hospital trusts responded to the requests for information, so the data were incomplete. Only 83 out of 164 responded with any data at all.

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[Andrew Gwynne]

The Labour party’s position is to support much of what the working time directive has brought about. Some real issues have been raised by Members of all parties in today’s debate. I recognise a lot of the issues and concerns, and it is incumbent on the Government of the day to resolve such matters to best suit the needs of the member state—in our case, the needs of the NHS throughout the United Kingdom. We support the working time directive, however, and its positive achievements, which have not been touched on to a great extent in today’s debate. There have been some positives.

We therefore have reservations about changes to the European working time directive. High-quality, safe patient care and the maintenance of further enhancement of the quality of training and education for junior doctors are important. I note the issues raised today, and specific areas must be looked at. We heard concerns about the maintenance of training standards, but patient safety must be paramount, and we should co-operate with all interested parties to develop sensible, workable and achievable solutions to the problems. If we allow a relaxation of the European working time directive for junior doctors, the danger is that we run the risk of a gradual return to their working dangerously long hours. I urge the Government to tread carefully because as the hon. Member for Bristol North West said, to be fair, some aspects of the working time directive had laudable aims. As was echoed in a number of contributions today, we do not want to see a return to the dangerous working hours worked by some doctors in the past.

[Charlotte Leslie]

Does the hon. Gentleman acknowledge that even if we relax the working time directive, with its detriments to the NHS, doctors would still be bound by the new deal and the 56-hour week? I see no return to the bad old days while the new deal is in place, although I think it, too, needs looking at again.

[Andrew Gwynne]

I shall come on to the new deal shortly, but no one would want to go back to the past with tired doctors working excessive hours. Many Members recall the very real horror stories that surfaced from time to time, in particular through the 1980s and early 1990s, when it was not uncommon for junior doctors to be working a 100-hour week, as we have heard in the debate. The hon. Member for Totnes called on her personal experience and the hon. Member for Stafford (Jeremy Lefroy) called on his domestic experiences from the past to make some reasonable points about the stress and strain that the old ways of working placed on doctors. I was reassured by their comments that they did not want to see a return to those days.

An article in the BMJ, the British medical journal magazine, looking at the effects of the working time directive, suggested that it was hard to draw firm conclusions. It also found that reducing working hours to fewer than 80 a week had not adversely affected outcomes for patients or in postgraduate training in the USA, where similar restrictions were introduced. As we heard from my hon. Friend the Member for Oldham East and Saddleworth (Debbie Abrahams), the systematic review found the same, and that cannot be discounted because it does not necessarily fit some arguments. I do, however, take full account of today’s anecdotal evidence from Members, although it might well be wise to look at the wider, long-term implications of relaxing some of the directive’s conditions.

If we go back a number of years, to the 1990s, the new deal tried to establish that full shift working should not exceed 56 hours. Through the 1990s, compliance with the new deal was poor, so a new contract was introduced in 2000. The implementation of the Working Time Regulations for employed doctors in the training grades has helped to protect doctors from working dangerously long hours, improving patient safety.

I accept, as we have heard from several hon. Members, that press reports of locum doctors costing hospitals and the NHS some quite extortionate amounts are concerning. Some reasonable points were made by the hon. Member for Central Suffolk and North Ipswich, who speaks with experience on these matters, about the clocking off and clocking on culture, which is certainly a concern. Clearly, questions must be raised about spending so much public money in these financially restricted times, and we need to know what will be the knock-on effect for the quality of patient care, especially if patients are continually seeing different doctors every time.

The Minister, in answer to the hon. Member for Kingswood (Chris Skidmore), mentioned the 11% drop in the use of locums since May 2010 and the increase in the number of doctors, which is welcome. I will just make the point that those extra doctors were trained and came through the system under the previous Labour Government. It would be churlish of the current Government not to recognise that as they take some political capital. May 2010 was not month zero; those doctors were coming through the system previous to that.

This debate has been a positive step. As we have heard, a number of issues surround health workers, especially junior doctors, and I agree that they should be further examined as we seek ways to resolve the problems. However, we should approach with some caution the idea of relaxing some of the directive’s conditions in relation to junior doctors as in the longer term it might cause more problems than it solves.

In closing, I refer to the opening comments of the hon. Member for Bristol North West in which she said that we all value the expertise and professionalism of NHS staff and that the aims of the working time directive were very reasonable. Long hours were dangerous for both doctor and patient and we do not want to return to those days. She is right. Although we recognise that there are issues to consider in relation to staffing implications and the cost to the NHS, we do not want to see the positives that have been secured disappear. I look forward to hearing from the Minister an indication of the current Government’s thinking on how to strike that important balance for those working in our medical and clinical professions in the NHS. I feel a bit like Daniel in the lion’s den. I urge the Minister to tread cautiously, and I mean that with all sincerity. Yes, there are some issues, but he really should resist the knee-jerk reaction of his party’s anti-EU wing, which is probably its mainstream. He needs to look holistically at the issues, the concerns and the benefits.

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[Charlotte Leslie]

Thank you, Mr Howarth, for allowing me to speak.

I look forward to the Minister’s further reply in writing. I should like to take this brief opportunity to thank him and hon. Members for furnishing this debate with such insight and, in many cases, experience. The hon. Member for North Antrim (Ian Paisley) used the F-word and is a true advocate of Cillit Bang for the gold-plating that this country seems to put on every piece of legislation that we have.

I am particularly grateful to my hon. Friends the Members for Central Suffolk and North Ipswich (Dr Poulter) and for Totnes (Dr Wollaston) for sharing their first-hand experience and knowledge. They talked about vocation and the meaning of that word in terms of professionalism. My hon. Friend the Member for Totnes proposed some constructive solutions about how we can mitigate the effects of the European working time directive, right here and right now.

We heard an account of first-hand experience from the hon. Member for Vauxhall (Kate Hoey), who talked about the director of St Thomas’s hospital and warned that the formal view of events is often far better than the real situation, which is often a lot worse and not always represented in formal evidence that is given.

I also give many thanks to my hon. Friend the Member for Stafford (Jeremy Lefroy), who gave yet more first-hand evidence from his wife and talked cogently about the recruitment lag that we are facing. He also gave evidence from the Association of Surgeons in Training about the two years of surgical training time that is lost.

Many other Members made extremely valuable contributions. I fear that I cannot mention them all because of the limit on time, but I must mention my hon. Friend the Member for Kingswood (Chris Skidmore), who provided a great deal of experience from the Health Committee. I know that other Members would have contributed immensely if they had been able to make a speech today, particularly my hon. Friend the Member for Camborne and Redruth (George Eustice).

I was encouraged that the hon. Member for Denton and Reddish (Andrew Gwynne) acknowledged the challenges that we face, but I am slightly cautious about the fact that he did not acknowledge the urgency of the situation or the strength of doctors’ evidence. One of the reasons why the new deal failed is that it did not bring on board the views of doctors as a whole. It failed because it did not bring doctors with it. I warn against ignoring doctors’ evidence on this front. I am very encouraged by the Minister’s remarks, but I hope that he will forgive me and other Members if we carry on campaigning and do not let this issue drop.