Editorials

The European working time directive for doctors in training

We will need more doctors and better organisation to comply with the law

On 1 August 2004 junior doctors in the National Health Service and other healthcare systems throughout Europe will no longer be excluded from the provisions of the European Working Time Directive.¹ Their working hours will then be limited by law, first to 58 hours a week and then, by 2009, to 48 hours. This will demand even more profound changes for the NHS than seen so far in the long march for better working conditions for junior hospital doctors.

The original directive on working time became law in 1993, but doctors in training were excluded, along with workers in the road, air, rail, sea, and inland waterway industries. The British government of the time challenged the validity of the directive as health and safety law, but it was confirmed in 1996 as such by the European Court of Justice.² There is overwhelming evidence that sleep deprivation, sleep restriction, and enforced unnatural circadian cycles contribute to cognitive and motor impairments, injuries, and error.^3-5 Doctors are not immune from these effects. ^{6 7}

The European Commission and parliament had always intended that the excluded workers should be brought within the provisions of the directive, and in August 2000 the original directive was revised,⁸ with a timetable for including the exempt workers.

For doctors in training there will be an interim limit of an average 58 hour working week from 1 August 2004. This will reduce to 56 hours from August 2007 and to 48 hours in 2009. Under certain undefined circumstances national governments may apply for a further extension of a maximum of three years to delay the final reduction to 48 hours.

It was initially assumed that the definition of work would be similar to that which applies to the 1991 "new deal" on junior doctors' hours.⁹ This agreement limited junior doctors' hours of work in the United Kingdom to 72 hours on duty and 56 hours of actual work: actual work is defined as time spent performing the duties of the post, such as admitting patients, carrying out investigations, giving treatment, but it excludes time spent resting in the hospital or elsewhere. A recent European Court of Justice ruling has, however, redefined work as all time spent on duty in the workplace.¹⁰ Thus for junior doctors in the United Kingdom the maximum average time spent on call when resident in hospital will be 58 hours per weeka 19% reduction from the current 72 hours.

Several other rules in the directive are also more stringent than those in the new deal. They include a requirement for 11 hours of continuous rest in each 24 hour period and a maximum of 8 hours of work in 24 hours for night workers. Not only the NHS but also many healthcare systems in Europe will need to undergo dramatic changes to comply with these rules.

Junior doctors, trusts, and NHS managers all have worries about the effects of the changes. Trainees worry that they can be satisfactorily trained. NHS managers worry about how to deliver a service which remains largely provided by junior doctorseven though the government has made a commitment to a consultant delivered service in the NHS.¹¹

The UK medical royal colleges accepted in 1991 that training could be delivered satisfactorily in 56 hours of work using new working patterns such as partial shifts and shifts.¹⁰ A recent major review of the new postgraduate medical training schemes¹² indicates that the clinical competence of senior trainees and new consultants does not seem to be a concern several years after the introduction of the new deal and in the context of reduced training times brought about by the Calman Report.¹³ Given the will and the investment, training can be improved and the working hours of doctors reduced. We will, however, need more doctors, better organisation of services, and improved training opportunities to expand the number of consultants needed. We need to ensure that there are enough doctors on duty at all sites to comply with the law and guarantee that caseloads are such that training and supervision of junior doctors will be satisfactory. Unlike the new deal, the European Working Time Directive is not a gentleman's agreement. It is health and safety law, and we have less than 1000 days to comply.

Trevor Pickersgill, chairperson, junior doctors committee. 

BMA House, London WC1H 9JP (pickersgill{at}ntlworld.com)

1.	Council Directive 93/104/EC. Official Journal of the European Community 1993; L307: 18-24.
2.	Judgement of 12 November 1996: Case C-84/94 UK v Council of the EU. European Court Reports 1996;1-5755.
3.	Williamson AM, Feyer A-M. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med 2000; 57: 649-655[Abstract/Free Full Text].
4.	Feyer A-M. Fatigue: time to recognise and deal with an old problem. BMJ 2001; 322: 908-909[Free Full Text].
5.	Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997; 388: 235[Medline].
6.	Taffinder NJ, McManus IC, Gul Y, Russell RCG, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet 1998; 352: 1191[CrossRef][Medline].
7.	BMA Junior Doctors Committee. Implications for health and safety of junior doctors' working arrangements. London: British Medical Association, 2000.
8.	Directive 2000/34/EC of the European Parliament and Council. Official Journal of the European Community 2000; L195: 41-45.
9.	NHS Management Executive. Junior doctorsthe new deal. London: Department of Health, 1991.
10.	Judgment of 3 October 2000: Case C-303/98 Sindicato de Medicos de Asistencia Publica (SIMAP) v Conselleria de Sanidad y Consumo de la Generalidad Valenciana. European Court Reports 2000;1-7963.
11.	Department of Health. The NHS Plan. London: Stationery Office, 2000.
12.	The Open University Centre for Education in Medicine. Evaluation of the reforms to higher specialist training 1996-1999. Milton Keynes: Open University, 2001.
13.	Department of Health. Hospital doctors: training for the future. London: Department of Health, 1993.