This page, published in May 2009, sets out the RCOG’s position on the impact of the Working Time Directive (WTD) on the delivery of obstetrics and gynaecology (O&G) services.
Currently, Trusts are working hard to comply with the WTD to reduce trainees’ working hours to 48 hours per week. In O&G, all but 11 Trusts look like they will be 48-hour compliant by August and the RCOG is advising these Trusts on different ways to achieve compliance.
There is a possibility that some Trusts may need a slightly longer time to ensure compliance and will seek a derogation, but the preferred view, in the interest of patient safety, is to achieve compliance in all Trusts. An application for derogation will entail providing detailed plans to the Department of Health to demonstrate a stepped approach towards full compliance within three years.
Some specialties feel that this reduction will have a negative effect on patient safety and medical training and are campaigning to keep working hours at 56 or 65 hours a week.
The RCOG is in favour of the 48-hour working week. The rate of emergencies on the labour ward is the same over any 24-hour period and, therefore, the RCOG believes that doctors working in such circumstances should not be working long shifts without adequate rest.
In seeking to achieve WTD compliance, the RCOG and the Royal College of Paediatrics and Child Health (RCPCH) published a joint report in July 2008 on how Trusts in England were fulfilling the WTD.1 According to the report, in O&G, many trusts were increasing staff numbers and redesigning their rotas to achieve compliance. It recommended that a mixed approach is adopted in the restructuring of services as this would help Trusts to meet with their WTD obligations. The working party also found an association between more consultants and better patient safety and training.
The situation in O&G
Childbirth is unpredictable and obstetric emergencies appear throughout the day. The RCOG believes that a 13-hour shift is the maximum length of time a trainee should be made to undertake per day. This does not contravene WTD regulations. Safety is compromised if fatigued doctors are made to work more hours. A recent study supports the notion that better care is provided if doctors have adequate rest.2 O&G trainees themselves have stated that working in shift patterns will improve their quality of life.3
A successful example of compliance
A recent scoping exercise conducted by the RCOG working party on the WTD revealed that maternity units in the North West of England are best prepared for the WTD.4 The Strategic Health Authority (SHA) showed excellent clinical leadership by devising pilot programmes in WTD compliance over eighteen months ago.
The SHA has in the most part gone for a trained doctor solution, employing consultants to provide some out-of-hours labour ward sessions while ensuring that they have a mixed and varied consultant post. This proves that with adequate resources and the appropriate infrastructure tailored to their local needs, Trusts should be able to comply.
The RCOG’s model for compliance
The RCOG believes that innovative workforce design is required to ensure that trainees receive adequate training, whilst also ensuring a safe and effective service. Maternity units are advised to ensure that formal hand-overs are embedded into the rota system and consultant evening sessions are part of negotiated contracts. The RCOG has asked that the level of training is preserved by ensuring that doctors, other than those in training, provide some out-of-hours sessions to enable trainees to be present during the daytime to receive training and supervision.
Studies have shown that increased consultant presence in the labour ward increases safety and decreases the intervention and operative delivery rates.5 Increased consultant presence will also result in more structured supervision of trainees.
The RCOG recommends that, to ensure that service delivery, training and safety are balanced, a consultant is resident on-call with trainees throughout the day and depending on the number of deliveries during the evening and overnight in some units.6 This requires some consultants to work out-of-hours sessions, with appropriate rest.
The RCOG believes that planning for a maximum working week of 48 hours will be better for trainees mothers and their babies. The RCOG does not support additional training numbers as this will result in the overproduction of consultants without posts but rather; an increase in the number of consultants working out-of-hours which will also improve the care of the woman and her baby.
According to the RCOG Medical Workforce statistics 2007, there were 1082 registrars in post (422 UK, 78 EU, 582 overseas), 1416 senior house officers (259 UK, 52 EU, 470 Overseas), 73 O&G trainees in Locum for Service (LAS) and 77 O&G trainees in Locum for Training (LAT) posts.
1. Children’s and Maternity Services in 2009: Working Time Solutions. RCOG/RCPCH/NHS National Workforce Projects, 2008.
2. The survey was carried out by Warwick Medical School and the paper was published in QJM. Read the abstract or read the story on BBC Online.
3. Survey of Training 2008. RCOG Trainees Committee, RCOG, London; February 2009.
4. Data from a presentation at the RCOG Clinical Directors Forum, 22 April 2009, London.
5. Spencer C, Murphy D, Bewley S. Caesarean delivery in the second stage of labour. BMJ 2006;333:613–4.
6. Ebulue V, Vadalkar J, Cely S, Dopwell F, Yoong W. Fear of failure: are we doing too many trials of instrumental delivery in theatre? Acta Obstetricia et Gynecologica Scandinavica 2008;87:1234–8.
7. Ekanem AD, Udoma EJ, Etuk SJ, Eshiet AI. Outcome of emergency caesarean sections in Calabar, Nigeria: Impact of the seniority of the medical team. Journal of Obstetrics & Gynaecology 2008;28:198–201.
8. Savage W, Francome C. British consultants’ attitudes to caesareans. Journal of Obstetrics & Gynaecology 2007;27:354–9.
9. See chapters 3 (Staffing roles) and 4 (Staffing levels) in Safer Childbirth. Minimum Standards for the Organisation and Delivery of Care in Labour, RCOG/RCM/RCoA/RCPCH; London, 2007.