UPDATE ON EUROPEAN WORKING TIME DIRECTIVE COMPLIANCE FOR JUNIOR DOCTORS / MODERNISING MEDICAL CAREERS

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1 ITEM SGC/2009/1 Staff Governance Committee 20 January 2009 UPDATE ON EUROPEAN WORKING TIME DIRECTIVE COMPLIANCE FOR JUNIOR DOCTORS / MODERNISING MEDICAL CAREERS 1. PURPOSE OF THE REPORT The purpose of this report is to provide Committee Members with an update on progress in relation to meeting the requirements of European Working Time Directive (EWTD) compliance for Junior Doctors hours of work and the impact of Modernising Medical Careers (MMC). A Glossary of Terms used throughout this report is attached at Appendix RECOMMENDATIONS The Committee are invited to note the work being undertaken in relation to meeting EWTD targets and to support the ongoing approach being taken by NHS Tayside to meet the target date of August In addition, Committee Members are asked to note the work currently being undertaken to manage the ongoing impact of introducing MMC. 3. EXECUTIVE SUMMARY Across NHS Tayside we currently have 111 trainee rotas, split between 87 Full Time and 24 Less Than Full Time rotas. 100% of all rotas are New Deal compliant. 100% of Less Than Full Time rotas are EWTD compliant. 53% of Full Time rotas are currently EWTD compliant. 75% of Full Time rotas have potential EWTD compliant solutions in place. 62% of all rotas are currently EWTD compliant. 80% of all rotas have potential EWTD compliant solutions in place. The following four rotas have been identified as being most at risk of failing to be made compliant by August 2009: Renal Medicine (Ninewells). This rota is staffed by a small number of trainees and the speciality is extremely intensive. We are recruiting an additional trainee in Aug 09 which should help to ease the problem. Coronary Care Unit (Ninewells). There are a small number of trainees on this rota and it is propped up by Research staff. It is difficult to alter their hours as they are employed by the University. We are actively working to resolve the problems associated with this rota. Paediatrics (2 rotas, both Ninewells). Vacant posts, combined with less experienced trainees have compounded the problem in Paediatrics. This is being reviewed at a national level.

2 The New Deal Monitoring Officer and Medical Change Projects Manager are meeting all specialities to identify their local plans for achieving compliance. Proposals include; reducing hours by removing certain shifts changing starting and finishing times introducing additional days off into rotas service redesign development of new cross-speciality working patterns development of new roles increasing use of consultant delivered service. The current Hospital at Night models in Ninewells and PRI are also being reviewed to see if they can cover more core competencies and so allow a reduction of the reliance on Trainees to provide cover both Out of Hours and during the normal working day. In addition, we are looking to develop Hospital at Night models for Psychiatry and Paediatrics. Work is already well under way for Psychiatry and work on the Paediatrics model has started with an Observational Audit, the results of which will be known early in This work will help inform decisions of potential solutions. The ongoing implementation of MMC is creating operational difficulties in some specialities because some posts advertised to start in August 2008 remain unfilled. This has been caused by a combination of factors, including: a reduction in the number of candidates applying for posts (because of changes to Immigration Policy at a UK level) English Deaneries uncoupled Core Training Programmes from Run Through Training Programmes, thereby making their training programmes appear more desirable to trainees, in the short term a decision to retain one-year Fixed Term Speciality Training (FTSTA) posts in Scotland, which trainees rejected if they were subsequently offered a Core Training Programme in England Policy changes have now been made in relation to FTSTA numbers. The majority of FTSTAs have been converted into Core Training programmes. This means trainees will receive a training contract for 2 or 3 years (depending on the speciality) after which time they will have to reapply through a competitive process for a Higher Speciality Training post. There have been initial discussions at a national level regarding the introduction of an Associate Consultant grade for Trainees who complete their training. This would enable the Service to provide a Trained Doctor service, without having to pay consultant salaries. Scottish Government Health Department, in conjunction with Health Boards and NES are also reviewing future workforce numbers (based on a trained doctor service). It is expected that this will lead to a sharp reduction in training grade posts, with a subsequent rise in trained doctor / consultant posts. Workforce modelling has not yet calculated the financial impact of this proposal. 4. MEASURES FOR IMPROVEMENT We will achieve EWTD target by the required date. Services will continue to be delivered and local / national Waiting Time Targets will continue to be met when compliance is achieved. 2

3 5. FINANCIAL IMPLICATIONS A reduction in hours for rotas may not necessarily lead to a reduction in Banding payments for Junior Doctors. In NHS Tayside we already generated considerable savings in banding costs when we introduce the Hospital at Night models in PRI and Ninewells. The savings went to pay for the nursing component of the new model. Some residual, ongoing saving continue to be made, however, as existing SpRs complete their training and they are replaced with new trainees. If anything, there may be an increase in staffing costs associated with delivering services, if additional staff have to be employed to fill the gaps left by Junior Doctors. Depending on the solutions proposed by Specialities these costs may vary. Some Specialities are proposing that consultants may have to fill some of the gaps left by trainees and this cost will be higher than the non-medical models which other specialities are considering. It is unclear what the impact of the new Staff Grade contract will have on costs and there are no firm proposals concerning the introduction of the Associate Consultant grade, which we could use to model future workforce requirements. Any financial modelling work will have to be based on current grades of staff. 6. DELEGATION LEVEL This work has been delegated to the Delivery Unit Medical Director. 7. RISK ASSESSMENT There are a number of risks associated with the delivery of these issues. For EWTD, failure to meet the 48 hour target by August 2009 may result in NHS Boards being subject to action under Health and Safety legislation. This ranges from fines, to employees taking employers to Industrial Tribunals for failure to meet the requirements of the legislation. Modernising Medical Careers contains its own specific risks which includes: failure to recruit to all our vacant training posts, and the knock on impact on rotas and compliance rates changes to the number of training posts allocated to NHS Boards (there is discussion about repatriating some training numbers to the West of Scotland), and the knock on impact to rota sustainability expansion of GP training to 4 or 5 years and using some FTSTA numbers to fill these training programmes. GP training will only pick certain specialities to support expansion and these may not be where we currently have FTSTAs. There are also unknown risks associated with the move to delivering a trained doctor service. It is not clear yet who will deliver this service, what grade of doctor will deliver this service, how much it will cost and whether there are enough trainees available to fill the posts when they are advertised. NHS Tayside is working closely with the North of Scotland Regional Workforce Director to address these workforce planning issues. There are national shortages of experienced trainees in some Specialities (specifically Paediatrics) for which National and Regional solutions are being developed. NHS Tayside will have to feed into these solutions and ensure that alternative proposals are developed to help maintain services in the short and medium term i.e. the next 5 years. Service redesign may have an impact on the hours worked by consultants and may result in 3

4 consultants having to cover more work out of hours, which could lead to a knock-on for work delivered during the day, with subsequent knock-on to Waiting Time Targets. Again, the impact of this will be determined by proposed local solutions. 8. IMPLICATIONS FOR HEALTH The complexity of managing the various strands of policy involved in this paper, along with the lack of local control (some of the issues are being handled at a Scottish or UK government level) may mean that failure to deliver on any one aspect could have a potential negative impact at a local level. This has not been quantified. 9. TIMETABLE FOR IMPLEMENTATION AND LEAD OFFICER We are required to comply with EWTD by August The Lead Officer for meeting this target is Professor Forsyth. 10. CONSULTATION INFORMING, INVOLVING & CONSULTING WITH PUBLIC & STAFF Staff groups, including the BMA, will be involved in the ongoing redesign work required to meet this target. 11. EQUALITY & DIVERSITY IMPACT ASSESSMENT If there is a requirement to redesign services as a result of work being undertaken at a local level, appropriate impact assessments will be carried out. Steven Haddow Professor Stewart Forsyth Head of Medical Change Projects Medical Director, Single Delivery Unit 12 December December

5 APPENDIX 1 GLOSSARY OF TERMS Term European Working Time Directive (EWTD) New Deal Modernising Medical Careers (MMC) Run Through Training Fixed Term Speciality Training Appointment (FTSTA) Full Time Rotas Less Than Full Time Rotas (LTFT) Hospital at Night (H@N) Description Legislation which has been introduced to reduce working time to 48 hours per week. It also incorporates rules governing maximum shift length, breaks and rest requirements and maximum number of continuous duty days. Introduced in 1991, and it was designed to support safer working conditions for Junior Doctors, regulating their duty and actual working hours. Introduced to speed up the time taken to train doctors, from leaving university, through to receiving their Certificate of Completion of Training. Currently starts with a 2 year Foundation Training program, which provides generic training. Then leads to Core Training (eg Medicine or Psychiatry) or Run Through Training ( eg Radiology or Paediatrics) Higher Speciality Training leading to Certificate of Completion of Training was previously known as SpR level training. One year contract which is recognised for training. These contracts have been used by Health Boards to prop up rotas, to ensure continued service provision. Rotas where trainees are contracted to work a minimum of 40 hours. Usually involves some out of hours working, which can be undertaken as a full shift, partial shift or on call from home. Trainees can request to train less than full time, usually to accommodate domestic or family commitments. In Tayside these trainees have traditionally been regarded as being supernumerary but this position changed with the introduction of MMC, and they must now be counted when developing a rota. The difficulty for services provision is that most trainees want to work 60%, which leave a 40% gap in the rota. A model for delivering services out of hours. Usually comprises a multidisciplinary team, of senior nurses, medical staff and support workers who can deliver more routine tasks. NHS Tayside currently has 2 models in operation at Ninewells and PRI. We are developing a model for Mental Health Services and paediatrics. It is hoped these will resolve some of the problems associated with the introduction of EWTD and MMC. 5