EU Working Time Directive (NHS)

Sarah Wollaston Excerpts

Thursday 26th April 2012 Westminster Hall

[Dr Sarah Wollaston (Totnes) (Con)]

I congratulate my hon. Friend the Member for Bristol North West (Charlotte Leslie) on securing this important debate. Why it matters so much is summed up well by Sir John Temple, in his report, “Time for Training”:

“Training is patient safety for the next 30 years”,

and that is absolutely right.

My own experience is as one of the junior doctors who worked those catastrophically long hours, having qualified at Guy’s in 1986. Before coming to the House, I was involved in teaching and training junior doctors and medical students, including F2—foundation year 2 —doctors, so I have the advantage of seeing the system from its very worst through to the current practice. What we had in 1986 was entirely unacceptable. I was routinely working 100 hours a week, and sometimes up to 120 hours a week. I often worked very long shifts, from Friday morning at 8 am through to 6 pm on a Monday, sometimes without any sleep. It was catastrophic, demoralising, dehumanising and, frankly, dangerous. Training was acquired simply through saturation exposure to techniques. Often the training was ad hoc and the supervision was not ideal. There was an ethical practice that we would find unacceptable today. Often the attitude was: see one, do one, and teach one. Sometimes the see-one stage was omitted.

I remember—I hope that this never happens now because it would be, and it was then, entirely unacceptable—having to insert a chest drain into a patient for the first time. I had a telephone propped on my shoulder and a terrified patient on the bed, but there was no alternative to carrying out the procedure. I am happy to report that the patient survived that experience, but it was not enjoyable for either of us. Both of us were half scared to death as the process went ahead. It was the equivalent of being bayoneted by someone who looks about 12 years old. As I have said, extra time was no guarantee of better training in those days. Happily, the NHS today operates to far higher ethical standards.

However, the firm structure that existed then guaranteed a continuity of care. There was not an issue about contacting the junior doctor because the junior doctor never left the hospital. Professionalism was affected in some ways, especially in the attitudes that were engendered. Sometimes there were very paternalistic attitudes from senior doctors, and certainly attitudes towards consent were not as high as they are today. That was engendered by very long hours and not enough attention given to the quality of training for junior doctors. In addressing this matter, we have to be cautious about referring to the old days as the good old days.

We now have a situation in which there simply are not enough staff to cover shifts. Clinics are routinely cancelled as a result of the inflexibility of compulsory rest periods. For example, if a consultant is called in to carry out an emergency endoscopy, they might then be forced to cancel their clinic for the next day, whereas if we had a little more flexibility about the timing of the rest period—perhaps it could happen within 48 hours—we would not see our patients being unnecessarily inconvenienced.

The availability of experienced staff is poor, as has been highlighted in many reports. Nor are we addressing issues of staff fatigue, to which other Members have referred. I want to read out an e-mail that I received this week from a junior doctor who did not wish to be named, who says, “I regularly do seven 13-hour nights on the trot. The argument is that we are given time off to average out our hours over a six-week period. However, we all end up doing the extra hours anyway, partly by covering for colleagues who are off or who do not exist, or simply by staying on after our shift’s end because there is so much more to do. So we foundation years are doing the long hours but we are just not being paid for them.”

Professionalism faces two problems: either junior doctors work the extra hours and are not paid for them, and are told not to record them sometimes by management; or we develop a clocking-off mentality, which I started to encounter towards the end of the time that I was training junior doctors. For the first time in my career, I heard junior doctors openly talk about clocking off and something not being their problem because they had handed it over to the next doctor on the next shift. That was unheard of when I was a junior doctor: we left when the job was done. We have to be cautious about some consequences in that regard.

Staff absenteeism, which is almost unheard of—I remember one of my colleagues getting tuberculosis and it being a great source of excitement for him, because it meant that he would have some time off for treatment—is increasing. According to a survey by the Royal College of Physicians, the absenteeism rate has increased from 0.8% to 3.5% since the implementation of the directive in 2009. Therefore, the changes towards exhausting shift patterns have not only not resulted in doctors who are less tired, but have led to increased absenteeism. Whether that is due to sickness or to a change in professional attitudes to taking time off is a fine point, but the implementation of the directive has led to serious consequences.

In my area, we have heard about some rotas starting at unacceptable times. I do not think that any hon. Member here would accept that starting a shift at 2 am is acceptable, but it is going on.

As hon. Members have said, we are hearing in our surgeries and postbags that patients and their relatives are noticing changes in continuity of care. The other serious issue is handovers, particularly where senior doctors or consultants are not present. The fact is that shifts do not tally up between junior and senior doctors. Again, referring to the e-mail that I received, on continuity of team, where senior doctors are in different shift patterns there is no sense of a team structure or possibility of handovers being carried out professionally.

[Margot James (Stourbridge) (Con)]

My hon. Friend is making an eye-opening speech. Does she agree that there are implications for health inequalities? For a patient who is well educated and knowledgeable about medical matters and/or has a supportive, informed family around them, the issue of handover is perhaps not as serious as for a patient who is not similarly advantaged.

[Dr Wollaston]

Yes, I agree. But even articulate families of patients tell me that sometimes they find it impossible to track down the doctor who has been looking after their relative. It is not just relatives, but general practitioners, who are having this difficulty. I am afraid that, as a result of this loss of continuity, the times have gone when GPs could phone and be guaranteed to have some feedback regarding patient care. Handovers have been identified, time and again, as a significant source of mistakes in the NHS, leading to incorrect diagnoses and treatments, often repeated, unnecessary or even inappropriate investigations and poor communication between patients, relatives and medical colleagues.

The directive results in poor team work, a loss of training opportunities and is, as we have heard—I will not repeat it—expensive, not only in terms of staff time, but in the penalties that are applied to trusts if they breach it. Finally, it does not stop doctors working at other hospitals, so it does not necessarily even address the problem that it was designed to address.

That is enough about the problems. What about the solutions? Nobody here advocates a return to dangerously long hours for junior doctors, because tired doctors are dangerous doctors. We want the safest care for our patients. I should like the Minister to respond to the idea that the definition of “on-call” is overly restrictive. Doctors should be able to sleep on site and be available for occasional emergencies without that counting towards the 48-hour week. The requirement for compulsory rest periods should be far more flexible on timing, and we need special consideration of the problems facing district general hospitals. The directive is one thing for staff in a metropolitan centre, but it is causing a particular crisis in many of our district general hospitals. We should maintain individual opt-outs.

The point about the European working time directive, as has been made so eloquently by the hon. Member for Vauxhall (Kate Hoey), is that European time is not the same as human normal time. Being realistic, the possibility of a rapid change in the directive is small, so we must look at the alternatives. What progress are we making towards a consultant-delivered service? There is no doubt that the directive does not affect all specialities, and its effect can undoubtedly be mitigated by moving towards a consultant-led service and taking up many of the points raised by Sir John Temple in his report.

There is no doubt that consultant-led care is the safest care for our patients. Much more can be done to make use of existing training opportunities. Not all specialties are affected, but when they are the effect can be mitigated by greater use of, for example, simulation, better design of rotas to enable the shifts and working patterns of seniors and juniors to dovetail so that there are better opportunities to train, using hospitals at night, and separating the emergency model from the routine model so that we have far more emphasis on juniors being able to get the training they need.

Real problems are facing juniors now with getting assessments signed off by senior colleagues, and in the level of their daytime routine supervision. The problem is also that they are not having enough experience signed off, so many doctors have to extend their training, which is a huge source of extra cost for the NHS. Some of that could be addressed with better rota and service design.

We all recognise that the NHS functions as a result of the dedication of its staff, and I pay great tribute to all my former colleagues, and recognise what an excellent job they do on our behalf.

--- Later in debate ---

[The Minister of State, Department of Health (Mr Simon Burns)]

It is a pleasure to serve under your chairmanship this afternoon, Mr Howarth. I congratulate my hon. Friend the Member for Bristol North West (Charlotte Leslie) on securing this debate. Anyone who listened to her speech this afternoon would realise that she is an expert in this area and cares passionately about improving the current situation, which, as it will become clear during the course of my remarks, is a problem for the national health service. I have considerable sympathy with the aim of her contribution—to get improvements and changes that will aid the NHS to help those who work within it.

We have had a particularly high-level and intelligent debate in which there have been some powerful contributions—surprisingly, not from many Opposition Members—from my own hon. Friends and the hon. Member for North Antrim (Ian Paisley). I would like to call him an hon. Friend because of the kind things that he said about me, but protocol forbids me as he is not a paid-up member of the Conservative party. None the less, my thoughts are with him in that respect.

There was an excellent speech by my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), who spoke with the authority of someone who was a consultant in a national health service hospital before coming to this place. Another powerful and highly informative speech came from my hon. Friend the Member for Totnes (Dr Wollaston), whose knowledge of the NHS has been gained through direct experience of working within it for many years before coming here.

We had a very interesting contribution from the hon. Member for Vauxhall (Kate Hoey), who cares passionately about this issue. My hon. Friend the Member for Stafford (Jeremy Lefroy) made a customarily well-informed speech based on knowledge gained partly from his experiences as an MP with the Mid Staffordshire NHS Trust in his constituency, and partly from his background interest in all health matters. I congratulate my hon. Friend the Member for South Northamptonshire (Andrea Leadsom) on a very powerful contribution. She rightly holds very strong views on these issues, and they are an important part of the debate. I congratulate my hon. Friends the Members for Hastings and Rye (Amber Rudd) and for Kingswood (Chris Skidmore), who both, in their own way, fight vociferously for their own local health economies in Hastings and in Kingswood, and show an interest in health debates.

All hon. Members are aware that this issue has been simmering, in one way or another, for many years. Recent news has shown us that dealing with the EU never seems simple, regardless of what is being discussed. I can understand the impatience of a number of my hon. Friends, because I, too, am impatient when I want something to be done that I think is sensible and should be done. Sadly, as we all know from our experiences of working within the European Union and of how that organisation works, we cannot always have instant gratification.

[Dr Wollaston]

Does my right hon. Friend think that one of the problems with the EU’s priorities is that it is demanding a 6.8% rise in its budget, rather than dealing with more pressing problems?

[Mr Burns]

I am tempted to go down that path, because I have considerable sympathy with my hon. Friend. However, time is short and I do not want to upset you, Mr Howarth. I will avoid temptation and keep myself on the straight and narrow.

We could not be clearer about how we want things to move forward. In the coalition agreement almost two years ago, the Government resolved to limit the application of the working time directive in the NHS. That position has not changed. We still believe strongly that working people should be able to work the hours they want. That means they should be able to choose to opt out of the directive’s limit on working hours. However, no one wants a situation where tired doctors are working for far too long, and for that reason it is important that doctors who choose to opt out, and their employers, agree working hours that ensure that patients are not at risk. A common thread running through the contribution of every hon. Member was the importance and necessity of not returning to what is known as the bad old days. Nobody on this side of the House, in any shape or form, would want that to happen. However, it is equally viable and intellectually respectable to argue for more flexibility, as the current situation —as highlighted in many speeches—is causing problems for the NHS. That has to be done in an ordered way. We cannot unilaterally take any action that would compromise the legality of how the European Union works, our contribution and how we operate within the EU.