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.
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.
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.
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?
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.
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?
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.
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.
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 Chris Heaton-Harris for anticipating that point.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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.
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.
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 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 autonomous workers, although that might be a complicated solution.
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?
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.
Thank you, Mr Brady, for giving me the opportunity to speak unexpectedly early in the debate; I really appreciate it. The European working time directive is a complete disaster. Those are the words not of some amateur politician, someone on the street, a journalist or a headline maker, but of the president of the Royal College of Physicians, Sir Richard Thompson. He has described the European working time directive as “a complete disaster” for both patient care and the quality of training. He said:
“We are not providing the service or the training that we require. I cannot overemphasise the damage to service provision and to training.”
The directive is a complete disaster in terms of providing a service to the people who need it the most—the vulnerable and the sick. It is a complete disaster to the physicians who are the lifeblood of the NHS; and a complete disaster to the future of our hospital structure.
In September 2010, the European working time directive impacted on hospital rotas. The Royal College of Physicians criticised “the reliance on locums” in rural hospitals in particular. It said that
“a service opt-out or modification should continue to be pressed for.”
The Causeway hospital in my constituency faces losing its accident and emergency department, which is the only such facility in one of the most rural parts of Northern Ireland. The area has one of the largest inflows of tourists at certain times of the year. Why is the department going to close? It is going to close not because it is useless or there is no demand, but because of its over-reliance on locums, which is a direct result of the European working time directive. It is a complete disaster for our rural hospitals. It is a complete disaster in terms of sickness leave among doctors. The report of the Royal College of Physicians, which was published in April 2010, shows that sickness leave has soared since the European working time directive was introduced. It says:
“The apparent rise in sickness rates of junior doctors since the introduction of the European Working Time Directive highlights the additional stresses that are being put upon trainees by new rotas.”
Let us not mince our words: this is a complete disaster. Let us be honest and say it as it is. As far as the NHS is concerned, the European working time directive has failed and we need to get a better plan or structure in place that coincides with the needs of patients and with the ability of our physicians to deliver the best care service in the world. The sooner that we call this as it is the better.
The hon. Gentleman is making a powerful case. Does he agree that the effects of the working time directive on our respective constituents is one reason why an increasing number of people are reaching the conclusion that we would be better off out of the European Union?
The hon. Gentleman pre-empts me. He is a mind reader. He seems to be able to find something that perhaps we are all agreed on. If the directive is a complete disaster; if it is starving our patients of good care and our junior doctors and senior physicians of being able to deliver what they are brilliant at delivering, we should address the problem at its root. The root cause is that we have a poison in the body politic of this kingdom. We are being regulated by people who do not live in this kingdom, do not care about this kingdom, are not part of this kingdom or do not have the needs of this kingdom at their heart, and we should stand up and recognise that. The over-regulatory practice that is being put upon us by Brussels is destroying this country. The sooner that we realise that, the better, and the sooner that the Government realise that and recognise that they should address the root cause of the problem, the better for us all.
The hon. Gentleman should just come off the fence. I have to declare that I was a member of the European Parliament for 10 years and served alongside his father. On two occasions, I attended an employment committee meeting in Brussels and saw Labour Ministers pleading with representatives to not allow the various connotations of the directive to flow through. Back in 2004, when the Commission opened up its first rethinking of this process, Labour Ministers came to the Parliament to plead with their MEPs not to vote to insist that this went ahead and to plead with the rest of the Parliament to allow Britain to do the right thing for its own people.
The hon. Gentleman gives us a valuable insight, or an inside track, into what the horse trading is really like in Brussels. This is not about the needs of the constituency or of the people, but about horse trading.
It is about what we can achieve here to solve something in Brussels, Lithuania or Greece that is completely unrelated to the health needs of this nation. That horse-trading mentality is failing this nation. The insight that the hon. Gentleman provides is useful, and I am glad that he has come out from the shadows of Europe and, like me, is standing here in this Parliament. I know the happy times that he spent with my father when he was in Europe.
Other nations do not gild the lily as we do. We are pretty special at gilding the lily. We can really implement regulations like no one else. Why do the Government do it? Every other European nation seems to interpret the European working time directive in whatever way they want and get away with it. I am amazed that Ireland—the other bit—has been able to interpret the directive its way and get away with it. Surely, if it can say that training is not part of being a doctor, we too can find the flexibility—a word used by Charlotte Leslie—necessary to make this work for us. Let us use the F-word; let us be flexible and get this right for our patients, our hospitals and our services.
In Lithuania, there is poor EWTD compliance because of the recession, so it can get away with it. Greece, too, has got away with not implementing the European working time directive because of its poor economic financial state. Surely, we can get away with implementing the European directive our way, and in a way that is flexible for our people and for our country. Apparently, Portugal is fully EWTD-compliant. However, many doctors and surgeons there now work more than their contracts say that they should. Surely, if the rest of Europe can find a way to be flexible to suit the needs of their people, it is not beyond the kith of men or beyond our wonderful Health Minister who is here today and our wonderful Department of Health to come up with a way to make the directive flexible for our people, for our nation, for our kingdom and—most importantly—for the needs of our patients, and to allow our doctors to deliver the service that they need to deliver?
I believe that we have a complete erosion of fundamental realities when we look at how the EWTD is being implemented to the destruction of the delivery of service and patient care. I hope that the Minister and the Department are listening to a voice that is coming across from all this kingdom, which says that the directive needs to be changed and changed fast.
It is a great pleasure to speak under your chairmanship, Mr Brady. I pay tribute to my hon. Friend Charlotte Leslie for securing this debate on an important issue in medicine and in improving front-line patient care that affects every MP’s constituents, whatever the constituency. I also pay tribute to Ian Paisley for a real tour de force in his speech just now. In my contribution to the debate, I will touch briefly on some of the points that he made, but I will try to expand on some of the points made by my hon. Friend.
My hon. Friend made a couple of very good points. Early in her speech, she pointed out the effect of the
European working time directive, saying that it has effectively taken 4,000 doctors out of circulation. Effectively, therefore, hospitals throughout the country have to recruit an extra 4,000 doctors as a direct consequence of the EWTD. That is a huge financial burden, but it is something that hospitals have effectively had to do in many cases and in many specialities in a very quick fashion—indeed, almost overnight. That has been very difficult to do.
Many hospital services in many parts of the country, particularly the more remote rural areas, are reliant on locum doctors, who are often not necessarily trained in Britain—not that that is a bad thing, because a huge contribution is made to the NHS by overseas workers. However, as has been very publicly highlighted by the Dr Daniel Ubani case, some overseas doctors are not necessarily familiar with the British medical system.
The failings of the EWTD and its implementation go further than just increasing the strain on doctors and the loss of continuity of care for patients. They relate to the way that hospitals have been forced to deal with the shortfall in their rotas and the problem of how they will look after their patients and to the fact that the system that is used to employ locum doctors is not fit for purpose. The General Medical Council and the British Medical Association are looking into those matters. Nevertheless, the failings of the EWTD has exposed a very important issue, and patients are suffering.
My hon. Friend also said that medicine is a profession and a vocation; I know that, too, and I obviously speak from personal experience. Medicine is not about clocking on and clocking off. It is about looking after patients effectively, whenever that may be. The result of introducing the EWTD has been to encourage hospitals, through fear of litigation, to encourage doctors to have a clocking-on and clocking-off culture. That is wrong; it is against the duties of the doctor, as laid down by the GMC; it is against what medical professionals want to do, because they care about their patients; and it is actually bad for patient care, for all the reasons that were outlined earlier by my hon. Friend.
My hon. Friend said that we do not want to go back to the bad old days of 100-hour weeks. I worked those 100-hour weeks, and I am sure that the other medical doctors who are in Westminster Hall today did so, too. It was certainly not ideal to work 100-hour weeks; it was not good for patient care. However, the point that was made earlier is that there is actually a happy compromise between doctors working a rota pattern—one that allows for training, continuity of care and proper treatment of patients—and ensuring that doctors have proper rest and are in a fit state to look after their patients. That happy compromise can be achieved. As has been highlighted already in speeches and interventions, it has been achieved in many countries within the European Union, and we should be able to achieve it effectively in this country, too.
The point that has been highlighted is that the previous Government dressed up the introduction of these reforms in the idea that they would be better for doctors with families and better for doctors’ training. In fact, neither of those things have actually come to pass. Doctors’ training has suffered as a result of the introduction of the EWTD in this country. Doctors do not get enough on-the-hour time with patients, and because many hospitals are forced into looking at service provision—in other words, having enough doctors on the ground as a direct consequence of the EWTD—the time allocated for junior doctors to receive proper training has been reduced massively. Given the rigid nature of the rotas introduced under the EWTD, they are often less family-friendly than rotas were in the past when doctors were asked to work more hours than now.
My hon. Friend highlighted the increased rates of sickness, particularly among physicians but also in other specialities where—quite rightly—an increasingly high proportion of women are entering the medical profession. In many cases, the reason why those women are finding things difficult and taking time off work is that they are unable to meet the demands of looking after their family properly. The fixed rotas are damaging to family life. My hon. Friend has made some excellent points.
I will now talk about a few other issues that are important to highlight in this debate. The Minister is working hard on our behalf to address the EWTD issue, by raising it in Europe for the Government and ensuring that we can put right what the previous Government got wrong. The issue of locum doctors goes to the heart of out-of-hours care. Many hon. Members, particularly those of us with more rural constituencies, have experienced the previous Government’s reforms of out-of-hours care by GPs. Thanks to those reforms, we now have a system that is not fit for purpose. We have locum companies running local out-of-hours care on the basis of care models that are, in many respects, not fit for purpose. Many locum companies often employ out-of-area doctors who do not understand local patients to run those services.
I am grateful to my hon. Friend for giving me the opportunity to make my point. Does he agree that there is also a great concern about the fact that other European legislation means that the GMC cannot systematically check locum doctors’ ability to speak English and communicate with their patients and that that is also putting patients’ health at risk?
My hon. Friend makes a very good point and the issue that I was just raising—that of locums and out-of-hours care—ties in very well with it, because those checks and balances very much occur in the sector of locum work. To fill staff vacancies in GP rotas in primary care and in hospital rotas, doctors are often rushed in at short notice from locum firms, even though we have not necessarily got the proper checks that would be in place when doctors are working in hospitals.
As I have said, doctors from overseas make a huge and valuable contribution to the NHS, but they do so when they have been familiarised with the British medical system and they are embedded in our hospitals up and down the country. However, there is a real danger: when we have an over-reliance on locums, which is a direct consequence of the EWTD, the problems that my hon. Friend has highlighted occur, and that has damaging effects for patients.
The key issue for me in this debate is the continuity of care. The point has already been made in interventions that bad things happen to patients at weekends and out of hours, because there are fewer doctors, nurses and members of staff working in the hospital. If we have a system in place whereby doctors are clocking on and clocking off and they are encouraged to do so because hospitals are worried about the dangers of litigation and that encourages the handover of information to another professional because people think, “I’ve finished now; it’s not my job anymore,” that will encourage bad things to happen out of hours.
On that critical point, is my hon. Friend aware of the effect that that is having on patients and their relatives? They know that something is going on. People are saying, “How is it that highly qualified doctors did not recognise that my relative, who was chatty, friendly and bright eight hours ago, is now distant and uncommunicative?”—something as simple as that. Without years of medical training, they know something is going very wrong.
My hon. Friend makes a very good point. Continuity of care really matters in terms of what is good medical practice, good for relatives and good for patients. Traditionally, one team took responsibility for looking after a patient and providing holistic care to their family, particularly end-of-life care or when a patient took a turn for the worse. It is not acceptable for a doctor with no previous knowledge of that patient or their family to deal with sensitive circumstances. Indeed, it is very difficult to have any sense of good care when care is continually handed over, in a pass-the-parcel fashion, to the next person who picks up the baton after a shift is timed out—that is not good care. It is bad for patients, bad for families and particularly bad for distressing end-of-life care and the care of the elderly.
For all those reasons, we need to sort out the EU working time directive. It is bad for medicine. It is bad for doctors. It is bad for doctors’ training. It is bad for patients. I know the Minister is on our side and that the Government are working hard. I look forward to hearing the Minister’s comments, and I pay tribute again to my hon. Friend the Member for Bristol North West for securing the debate.
I, too, pay tribute to Charlotte Leslie for her tireless work on this issue. I was pleased to be able to add my support to help secure the debate. It is a pity it is not taking place in the main Chamber, but it is great that we are having it and it shows to the Government the level of concern. Many hon. Members wish to speak, so I will be brief.
I come here not as a medical practitioner or as someone with any real medical knowledge, but as someone who cares deeply about the NHS and patient care. The hon. Lady outlined the difficulties very clearly, and in detail. We will hear many examples of what is wrong with the EU working time directive and its application to the NHS. We have to remember right at the beginning that the NHS is not a tick-box system of bureaucracy; it is about the care of patients, and the care of patients is in the hands of the people who work in it. If we allow the standards and the professionalism of our NHS work force to deteriorate because of the directive, we will leave a legacy that, in many years to come, we will look back on saying, “How could we have let that happen?”
I am privileged to have a great teaching hospital—Guy’s and St Thomas’, which is very near this place—in my constituency. A tremendous amount of effort has gone in to ensure that patient care is at the centre of everything that happens there. A terrific amount of work was done by the previous chairman, Patricia Moberly, to ensure that, fundamentally, everything that happens in the hospital is about patient care. It does not just serve its local community of Lambeth, but the whole of London, the whole of the country and patients from all over the world.
Understandably, the trust has implemented fully the EU directive. It is not, as was made clear to me, in the business of breaking the law. However, I have had many discussions about the directive, and the medical director of Guy’s and St Thomas’ told me that, despite doing everything possible to utilise more consultant presence out of normal working hours, and making every hour and minute count while a doctor in postgraduate training is at work,
“We are still left with a rigid template which is now seemingly outdated and needs revision for professional training.”
Many points have been touched on, but he raised the specific issue of the 13-hour shift limit leading to multiple handovers in a 24-hour period. He suggested that even an extension to 15 hours on weekdays, with appropriate compensatory time off later, would deliver a service with better continuity of care.
The medical director also raised the following important points:
“Many doctors in postgraduate training live in other towns and cities due to the rotational programmes of hospitals involved in their training. At weekends with 12 hour shifts, and with limited public transport services, especially on Sundays, there is more exhaustion from difficult commutes and two or three 12 hour shifts across a weekend rather than doing 1 X 24 hour shift with a better work life balance. We find that doctors try to re-organise their rotas to do this but we advise them that the EWTD does not allow this.
Doctors in craft specialties have fewer cases in their log books and less experience before gaining the certificate of specialty training than before. Perhaps they should be allowed to be with their consultant in an apprenticeship observer role to enable further exposure without being the provider of care to a patient beyond their…allowance.
Doctors in post graduate training should not feel that they are not allowed in the hospital beyond 48 hours. They should feel enabled to be in a learning environment— and be able to—
“develop as a professional. Patient care is a 24 hour activity and EWTD has led to fewer doctors being in the hospital out of normal, working hours. This is inconsistent with activity in hospitals going up all the time, at all times.”
That is the formal response from my wonderful hospital. There are many other things that they would not want to put down on paper or read out in the Chamber, and I can understand why. From talking to many doctors, both training doctors and doctors with more experience, we know that what is actually being said is more serious than what is being said officially. It is much more stressful for many doctors to work in those patterns.
One close friend of mine who is a young doctor says that in the old days—I am sure we all remember the old days—a firm of doctors would be responsible for their patients pretty much all week, and on call on top of that. That meant good continuity of care that benefited patients and contributed to training. Doctors could see whether or not their treatment had worked. Now they have lots of zero days that interrupt the working week and mean that the teams are smaller day to day. It is rare for more than two to work together. That means that patients are seen by different people every day who do not know their case. They have repeatedly to answer the same questions, and getting things done takes longer because they do not know who has actually asked for something, perhaps earlier that day.
Quite rightly, hon. Members are very concerned about the impact on patient care, but is the hon. Lady aware of any work that has considered the financial cost of this regulation to the NHS?
We do not have to be GCSE standard—I have more than GCSEs, incidentally—to work out that it clearly costs more, because more and more locums have to come in, and extra people have to come in from abroad. Like agency nursing, that costs much, much more. I can never understand why, instead of bringing in agency nurses and paying more, we cannot have more nurses. The cost is a huge factor and it is going to get worse. With reductions, people will have to be more careful, and this will be a big issue. It is not good for doctor training—they cannot do their job properly and it is more stressful.
Nobody will admit that there is a huge amount of fiddling of figures going on. The only way that people in charge know that they are perhaps going to save people’s lives is to fiddle the figures and allow people to work outside the law. That is absolutely not trying to encourage that kind of behaviour in the NHS. I do not blame people for doing that, but it is a direct result of how we have got ourselves into this situation.
The Government are apparently saying that they are working urgently with Europe. I do not want to turn this into a debate on Europe. I think most hon. Members know my views on that. No matter how hard or urgently the Minister is working in Europe—I know what a good Minister he is—Europe’s idea of urgency and ours are a long way apart, so we have to find another way. Ultimately, as Ian Paisley said, this is about getting to the root of the issue. We live in an independent country and what we do in our hospitals and our NHS service should not be decided by bureaucrats in Brussels, with Governments misguidedly signing up to all sorts of things that the people of this country have never had any say in.
I will go back to what I say in every debate on Europe: it is time for the people of this country to have a say on what they feel their relationship with Europe is all about. An important part of doing that is to get the European working time directive changed, so that we can honestly say that we parliamentarians have done our bit to ensure that patient safety is improved and made better than it will be if this continues.
I congratulate my hon. Friend Charlotte Leslie on pursuing this matter with vigour over many months—indeed, for more than a year.
I first became aware of the problem of doctors’ hours, particularly those of junior doctors, about 29 years ago when I started to go out with one, because I never saw her. I am happy to say that she is now my wife—and now complains that she never sees me, but that is another issue. In those days, many doctors worked what were called one-in-three or one-in-two shift patterns. There was even a celebrated one-in-one shift pattern right here in London, although I forget at which hospital, which meant that the junior concerned was in the hospital for six months, 24/7, without coming out unless the consultant allowed him or her—in those days, usually him; I am glad that, these days, it will probably more often be her—to leave the hospital. Those days, thankfully, are gone. I remember the doctor to whom I am now happily married working non-stop through a weekend. I wondered, in the end, however good a doctor was, whether patient care and safety was given sufficient consideration, and frankly it was not. That was so across the NHS. As all hon. Members have said, we are not going back to that stage: we will not and should not. This debate is not about that.
I also bring into play my experience as the Member of Parliament for Stafford, where, I am glad to say, things in the local hospital are improving steadily. We expect to hear about Stafford, and the whole NHS, in Robert Francis’s report later this year. Great efforts have been made to improve patient care and safety in my local hospital.
This debate is happening because all hon. Members are concerned about patient care and safety, not because we are all anti-Europe or want to find some fault with the European Union. It so happens that, in this case, the EU is causing the problem. Therefore, we have to bring that into the mix.
We introduced the European working time directive into the NHS with too little forethought. One reason in particular comes to mind. As we have heard, we needed some 4,000 extra doctors to take up the extra work that was required due to the imposition of the EWTD. Where were those doctors to come from? I pay credit to the previous Government for setting up several new medical schools, including one at Keele in Staffordshire, which are beginning to provide a stream of excellent new qualified doctors into the NHS. That is a positive step, but there was a disconnect between the timing of those doctors coming into the system and the European working time directive’s coming into force in the NHS in 2009. That has caused a major problem that I will mention briefly later.
I do not want to go into all the details, because hon. Members have covered them well. Suffice it to say that the categorisation of on-call time is one of the most important factors. As we have heard, Denmark, Greece, Ireland, Poland, Slovenia and Spain all have different ways of allowing on-call time to be counted: not as full hour for hour; perhaps as partial hour, or not at all; using a form of words such as “It’s training, not work”—I would hesitate to say that there is a difference between training and work—or using a contract-based rather than a person system.
There is a problem, however, although it is not one dreamt up by parliamentarians. Let me quote from a letter that I received from the Association of Surgeons in Training in the west midlands last year, which first brought the issue to my attention in detail, although I had been aware of it in general. Mr Henry Ferguson, who is the west midlands representative, wrote as follows:
“The EWTD is putting surgical patients at risk by producing thin layers of medical cover with frequent handovers. There are not enough surgeons to cover shift rotas and therefore there is inadequate staffing, particularly overnight and at weekends. Due to this shortfall, more locum doctors are needed to cover gaps in NHS shift rotas… Unless the restriction to a 48-hour working week is solved, the next generation of consultant surgeons will be short of experience.”
That is absolutely the case. I have spoken to friends who are consultant surgeons and they reckon that perhaps up to two years of training is lost. Surgeons, in effect, have to be trained for two years longer under the current scheme than under the old scheme. There is also a knock-on effect, if we are to have surgeons who are ready to fulfil the high expectations that we rightly have of them.
What are the consequences? I have already referred to training, and the figure of 65% of surgical trainees saying that training has suffered has already been quoted. My hon. Friend Dr Poulter talked about the problem of handover, which I link to the loss of continuity of patient care under the general heading of patient safety. Under the old system, one consultant and one firm would be responsible for a patient all the way through the journey through the hospital. Yes, there were problems and not everything went right, but we knew who was responsible for the patient. As we have heard, however, handovers can cause a tremendous loss of data in some cases, particularly when they are done between people who are extremely tired—certainly the ones handing over are tired, after many hours at work. The cost, too, has already been referred to; in my own hospital, a locum was apparently paid £5,667 for 24 hours’ work. That case is not exceptional, and we have heard other, equally astonishing ones.
Finally, returning to recruitment and the disconnect between the time of a new flow of doctors coming through from our medical schools and the implementation of EWTD in the NHS, I have already referred to the problems caused. In my own hospital in Stafford, for instance, as well as in many others throughout the country, we are seeing a real problem in getting doctors, particularly for emergency departments. As my hon. Friend the Member for Bristol North West said, we fear that certain specialties will become less and less attractive. Medical students now will rightly look at what offers not only a chance of a really fulfilling career but, at the other end, a good work-life balance. If they see that certain specialties do not, they will reject them and we will continue to see shortages.
We have heard some excellent suggestions from my hon. Friend on the way forward—recategorisation of on-call time, a section-wide opt-out, perhaps, or legislation allowing certain professions to work at higher minimum hours per week—and all such things should be looked at. I am grateful to see in his place the Minister who has done so much for the NHS in the two years since he took office. I very much urge him, however, to work even harder than he is already is to ensure that patient care and safety are put at the heart of the NHS in that most important respect.
“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.
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.
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 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.
I am delighted to follow my hon. Friend Dr Wollaston. What a fascinating speech, and what a fantastic insight. I congratulate my hon. Friend Charlotte Leslie because, so often, discussions about EU legislation revolve around the EU itself, but she brought to life the practical implications of EU legislation that is having a real impact on our society and patient care in the UK.
Article 168 of the EU treaty states:
“Union action shall respect the responsibilities of the Member States for the definition of their health policy and for the organisation and delivery of health services and medical care. The responsibilities of the Member States shall include the management of health services and medical care and the allocation of the resources assigned to them.”
It is fundamental in the treaty that health is simply not an EU area of competence. All that we are hearing about today is the unintended consequences of something that was introduced for an entirely different purpose. I want to go into the background of that.
Hon. Members will know that I have been involved with an all-party group on EU reform, and with the Conservative end of that—the Fresh Start project. It is trying to look at precisely how Britain could renegotiate a better relationship with the EU that would work in Britain’s better interest. The very first area we looked at was the working time directive. We looked at the headline figure that the cost to the UK economy is about £2.6 billion per annum, which is a real issue for us at this time. In its research, Open Europe suggested that halving regulation could deliver a £4.5 billion boost to GDP in the UK. What was slightly less expected from the research was the fundamental effect on the NHS, precisely because health is not an EU competence.
Why should that be the case? The all-party group recently visited the EU to talk to our MEP group and to commissioners about the working time directive and the impact on the health service. Our MEPs told us that the directive is the least popular piece of legislation ever introduced by the EU, and that 16 of the 27 member states have negotiated opt-out arrangements. Interestingly, under the Lisbon treaty, if a majority of member states get together and propose a reform, the European Commission and the European Council have to look closely at it and consider repeal of the legislation. I find it astonishing that we have not taken the lead so far in doing just that. It would certainly be worth considering.
Thank you, Mr Howarth. Occasionally it is difficult to remember that we are not having a conversation.
The point about the opt-out is that, under the working time directive, individuals can opt out of the maximum 48 hours per week if they choose to do so—they cannot be compelled to do so.
Is the hon. Lady suggesting that we opt out of, for example, co-ordination on public health strategy or communicable diseases? Co-ordinating at an international level on bird flu and other pandemics is hugely important.
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.
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.
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.
It might be helpful if I give my hon. Friend the answer to her question about when one can opt out and whether one gets paid. A doctor can opt out at any time with the agreement of the employer, and the junior doctors are expected to work up to 56 hours because of their contracts. If they work more than 56 hours and it is agreed, they will be paid for those hours.
I am grateful to my right hon. Friend for that important clarification. He will note the experience of the case study that I have just read out. There is an uncertainty about payment for extra hours and the recording of extra hours. That is clearly an issue that needs to be resolved at the sharp end, if not in the principle.
If it is of any help to my hon. Friend, I will re-clarify the matter. Junior doctors will be paid for hours over the 56 hours in their contract, but it is only with the authorisation of the employer that they can work those hours.
I am grateful to my right hon. Friend. As my hon. Friend the Member for Bristol North West pointed out, representatives of doctors and NHS staff do not agree among themselves about whether they support the European working time directive. Certainly, the Royal College of Physicians, NHS Employers and the Royal College of Surgeons are concerned not only that the working time directive causes a problem for doctors and patients, but that it does not do what it sets out to do, which is to deal with the exhaustion of doctors themselves. The Royal College of Surgeons says:
“We know from our members that working in a full shift pattern is more tiring when compared to working using an ‘on-call’ system, and creates a working environment that is impairing to patient safety.”
The British Medical Association believes that the European working time directive is entirely right in all of its manifestations. Patient and doctor representatives need to resolve the question of where they stand, as representatives of health service workers, on the implications of the working time directive.
Turning to the options for change, the Fresh Start project has done a great deal of work on this. Certainly, there are things Britain could do in isolation to try to improve the situation, and we have heard about some of them today. Some doctors in other European Union countries have two contracts, which has been used as a way of getting round the working time directive. We have heard about all sorts of workarounds that Britain does not tend to use, and the Government might want to consider what other countries have done. Certainly, MEPs in Europe have told me that some doctors will take on two 48-hour contracts, which seems to be going back to dangerous practice. Nevertheless, if an impossible situation is created, we end up with people just trying to defeat the problems.
A far more likely scenario is that we negotiate for change with other members that are unhappy with the consequences of the working time directive. We should get together with the 16 other member states that are determined to see change and that have negotiated an opt-out, so that we can get the directive changed specifically in relation to the NHS and make our economy more flexible.
What we are proposing is a concrete option for change. At the time of the European members’ attempt to get their recent fiscal consolidation agreement into the main treaties, there will be an opportunity for Britain to go to the EU Council with its own proposal for change. This is a clear opportunity, which has arisen from the need for fiscal consolidation in other EU countries, for Britain to prepare a list of changes to various elements of the treaties that it would like to see, and to go all out to negotiate those changes when the time comes, in three or four years. In line with the proposal put forward at the all-party parliamentary group for European reform, I recommend a triple lock whereby Britain arranges to opt out.
This is an interesting and useful debate. Is the hon. Lady aware of the recent systematic review—the highest level of evidence we have—that was inconclusive on the impact of the working time directive? I think there has been only one UK study undertaken since 2009, and one recommendation in the systematic review is that there should be more research. Is that not one of the outcomes we should be pressing for here, so that we have a full, evidence-based understanding that will enable us to ensure that policy is adhered to correctly?
I thank the hon. Lady again, but a mistake that many Opposition Members fall into is to think that only the European Union can legislate to protect the British NHS. Of course, that is simply not the case. Britain is perfectly able to legislate for its own NHS needs without the support of the European Union.
I would like to finish now. I have given way to the hon. Lady twice.
The first lock would be for the UK to argue that it should opt out completely from the social policy section of the EU treaties. The second lock should be for the UK to have the ability to opt out of any future EU proposal that it believed would impact intolerably on its social and employment law. The third lock would be for Britain to negotiate that the ECJ should not be allowed to have jurisdiction over ruling whether the UK was right to opt out of that legislation. That is the only way, once and for all, to enable Britain again to have control over its own working time hours—not only for the NHS, but for the future of the whole of our British economy.
It is a pleasure to follow my hon. Friend Andrea Leadsom who, as always, speaks with such authority on the relationship between this country and Europe. I was particularly interested to hear the relevant experience of my hon. Friend Dr Wollaston. Most hon. Members have said that we do not want to go back to 100 hour weeks; her rather shocking and frightening examples remind us all why that is so. What we want is flexibility—F for flexibility, as Ian Paisley so helpfully put it—so that we can try to get a better outcome for everybody.
So much has already been said and covered, particularly by my hon. Friend Charlotte Leslie, who did so well to secure the debate. As she made her remarks, I was concerned that she was going to cover absolutely everything. She pretty much did, so I will just concentrate on one area—surgery—where the effect of the working time directive has been particularly damaging.
Although, as some hon. Members have pointed out, the British Medical Association has said that all training can fit into 48 hours, surgeons I have spoken to are concerned. The body that represents trainee surgeons, the Association of Surgeons in Training, has stressed that surgery is very different from all other aspects of the medical profession. It has clearly taken on the BMA in trying to make that point. As Kate Hoey said, surgery is a craft specialty like chefs, for example—a lot can be learnt from books, but in the end there is nothing like hands on practical experience. Operative and procedural skills define the surgical craft and they are finite in number, with the majority to be gained during working hours. By limiting those hours, we are working against their training and therefore their competency as future consultant surgeons. As the ASIT survey confirmed, the majority of surgical trainees would welcome the opportunity to work in excess of the hours permitted—we are not doing them any favours by restricting their hours.
The Royal College of Surgeons estimates that 400,000 hours of surgical time are lost every month. ASIT believes that the restrictions imposed by the directive will be detrimental to the quality of training for junior surgeons and, therefore, to the quality of surgical service and provision in the future. Ultimately, as said by many of my colleagues today, the restrictions will be harmful to patient care. We also risk deterring junior doctors from specialising in surgery, as they are only too aware of the consequences of the restrictions. The royal college and ASIT both call for flexibility to enable UK surgeons to work up to a maximum of 65 hours per week, including time spent on call.
In addition to the effect of the working time directive on doctors’ training, the legislation is impacting on the continuity and quality of patient care in our hospitals. According to a survey by the Royal College of Surgeons, 80% of consultant surgeons and 66% of surgical trainees said that patient care had deteriorated as a result of the directive. Those consequences are worrying, and we need to focus on them.
In an earlier intervention, I referred to the systematic review. I appreciate that surveys give a certain amount of one-off evidence, but systematic reviews are the strongest form of evidence, and there were no conclusive results regarding an impact on patient outcomes. Whatever action we take, it surely should be based on the strongest evidence and not on evidence of lesser quality.
Anecdotal evidence is absolutely relevant. We get such evidence from talking in our hospitals to consultants, patients and surgeons. That is much more relevant sometimes than the box-ticking consequences from a more desk-driven survey.
Our 24-hour health service has had to make dramatic changes to how hospitals are staffed. The effects of the reduction in hours have been further compounded by the Jaeger and SiMAP rulings of the European Court of Justice, referred to by my hon. Friend the Member for Bristol North West. Those decree that all time spent in the workplace should be regarded as work, whether at rest or not, which is a dramatic change from previous arrangements. As a result, hospitals have had to scrap all on-call arrangements in favour of full shift rotas, which is creating a multitude of problems. Consultants at the Conquest hospital in Hastings told me that, in order to staff a full shift rota in one department, they now need eight people instead of the six they used to have on the old on-call system. Sometimes there is not even enough work. Indeed, the exposure of each doctor to training opportunities in the day is diluted, and the extra doctors are employed purely to service a working time-compliant rota.
The rota and the system are driving health arrangements, which is surely wrong. It is an inefficient and costly way to manage doctors, and it is damaging to the quality of their training. It is particularly harmful for district general hospitals such as my own, the Conquest, which find that they are no longer able to support certain specialties, such as the neurology department in my example, which has now largely moved to the nearby Eastbourne general hospital. Unfortunately, as we have heard from other Members, the same impact on certain specialties is being experienced in their district hospitals. The doctors at the Conquest do a fantastic job, and I am extremely grateful for the hard work and commitment that they put in; but, from my conversations with the consultants, I know that those doctors are being stretched too thin.
I have the privilege of representing a constituency in which the Royal Cornwall Hospitals Trust has another of the district general hospitals described by my hon. Friend. Does she agree that in remote rural areas with sparse populations, the impact on patient care of having to travel many miles to access specialist care will have a detrimental effect on treatment?
I wholly agree with my hon. Friend, who makes an important point about that particular problem for rural hospitals.
The shift system means that, instead of continuity of care, patients see—as we heard earlier, and I shall repeat the unpleasant phrase—a conveyor belt of doctors. Doctors do not get what they want either, which is to see patients through to treatment. Each time one shift ends and another begins, we have the handover process. As a consultant surgeon from the Conquest hospital said to me, someone unfortunate enough to be admitted to hospital at 7 pm on a Sunday evening would see four different sets of surgeons in just 24 hours. I know that there have always been handovers, but there are now more than ever, and each handover creates a risk of vital information being missed. We heard earlier about Chinese whispers, when expertise and important details may be lost. What is more, doctors are now under time pressure to clock off, so the chances of further mistakes are increased.
The Health and Social Care Act 2012 rightly puts doctors at the heart of the NHS, because they are best placed to manage the service and to deliver better results for patients. It is the doctors who are calling out for regulation to be relaxed, and it is essential that we listen to their cries for help. I am calling for a compromise and some flexibility that allows individual doctors and departments to make sensible decisions. Surgeons are asking for a maximum of 65 hours a week, including time spent on call, and that seems sensible.
We also need flexibility in how on-call time and compensatory rest for trainees are calculated. If a trainee wants to stay after their shift to watch an operation, to learn, and to benefit their training, they should be able to do so. We all want tomorrow’s doctors to be as good and as experienced as today’s doctors, so we must allow them to be the doctors that we expect them to be. We trust doctors with our lives, so we should trust them when they tell us they need more time to train.
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 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
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 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.
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.
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.
Is that not the point? This is about ensuring that we have quality data to inform policy development. It may not be working as it should be—I will accept that—but we cannot use incomplete, poor data to propose solutions. We need to ensure that we have quality data to inform that process. What if I made a statement now and that was regarded as evidence? Surely we are not going to base policy on just one person or on poor data.
I agree. I am sure that all hon. Members would echo such a call. We should have complete data. The complete data, if we had them, would show that the situation is far worse and that, instead of the £1 billion a year cost, the hidden cost is, according to the data that I have, perhaps £2 billion. We do not know.
My hon. Friend the Member for Bristol North West, almost like a Cassandra, warned that this would be a problem back in 2010, and started the campaign with no data at all. Two years down the line, we find what she said to be true, in respect of data from individual trusts. We will know more, probably, by the end of this year and there will be more stories in the Sunday papers and it will become an ever bigger issue. That is why it is so important to have this debate now, because when the public and patients who use the NHS ask, “What were you doing about this, as MPs?”, we can say, “We’ve had this debate. Okay, it’s not come up with all the solutions just yet”—we are interested to hear what the Minister says about possible solutions—“but we are on the case.” That is important, because an avalanche of cases will come forward in the near future. It is important to recognise that.
There is a challenge from Nicholson and we need to make those savings. The problem is that this matter is standing in the way of the Nicholson challenge being effectively delivered. Either we have to push harder to gain those efficiency savings—the problem now is that we have inefficiencies of the worst kind and are essentially having to make more efficiencies elsewhere to reinvest in front-line care—or the money will not be reinvested back into front-line care. Working time directive costs are classed as front-line care, when clearly they are not, so money is being removed that could be spent on nurses or on alternative equipment for the NHS that would have benefited patients.
My hon. Friend might find it helpful to know—he is talking about the Nicholson challenge and asking, “What were we doing during this”—and might take some comfort from the fact that, since May 2010, the cost of locums has fallen by 11%.
I appreciate that information. I only have pre-coalition data from 2007-08 and 2009-10, although they are not inaccurate. It is interesting to note that, before the coalition came in, the cost of locums was rising enormously, from £384 million to £758 million. The coalition’s inheritance was enormous. It is good to hear that there has been an 11% saving, which is roughly £75 million.
Let me give my hon. Friend the precise figures on the savings. The number of people employed as locums by the NHS has fallen by 11% since May 2010, and the number of doctors in the NHS has increased by about 4,000.
I welcome those figures. The coalition Government clearly recognise that front-line care is in danger of becoming atomised. We want continuity of care and front-line doctors, and we want full-time doctors and nurses rather than locums. Over the past couple of years—I am not blaming any one Government in particular—we have seen a sort of fragmentation and atomisation so that we now have 50 agencies delivering locum services, one of which has a turnover of £100 million a year. We need to look at that issue. The working time directive has been blamed for the rise of locum doctors, and it is good to hear that the coalition Government are making strides to change that, and we must recognise that in this debate.
The issue of training has been raised, as well as the fact that 400,000 hours of surgical time are lost every month—that is 4.8 million hours every year. My hon. Friend Amber Rudd was very informative about the impact that that will have on surgery as a craft, and I appreciate that. Professionalism is an issue, and the clock on, clock off attitude is not what any of us wants to see in the NHS. We want professionals to be in charge of their services in the NHS, and such an attitude clearly puts them out of charge.
“determination to support efforts to resolve these difficulties and be ready to work constructively with the European Commission and other member states on radical, creative approaches to gain additional flexibilities.”—[Hansard, 9 June 2010; Vol. 511, c. 14WS.]
“My hon. Friend raises an important issue about the working time directive and its effect on the NHS. Nobody wants to go back to the time when junior doctors were working 80 or 90 hours a week, but I think we all see in our constituencies that the working time directive has sometimes had a bad effect on the NHS…The Health and Business Secretaries are committed to revising the directive at EU level to give the NHS the flexibility it needs to deliver the best and safest service to patients. We will work urgently to bring that about.”—[Hansard, 18 January 2012; Vol. 538, c. 745-6]
My hon. Friend, and others, have spoken about other countries such as Spain, the Netherlands, Ireland and Portugal, which all somehow manage to get around the directive. I was interested to read my hon. Friend’s article in The Times where she wrote about what happens in the Netherlands and stated that Dutch trainee doctors are categorised as autonomous workers because they earn more than three times the national minimum wage. Being classified as working for themselves exempts them from the directive. There is a similar situation in Ireland where training has been exempted from the definition so that work done by trainee doctors falls outside the directive.
We must either look at the EU angle—many Members have raised the issue of the European Union—or at what the British Government can do within the NHS. GPs are self-employed. Can we not think radically and ask to what extent doctors working in hospitals could also be classed as self-employed so that we can get round the regulations? That is worth thinking about, although I am not sure what the consequences would be.
I really do not want to be a clever clogs. My hon. Friend has accurately described what happens in the Netherlands, but even with the opt-out, weekly hours in that country are limited, in that case to 60 hours.
Sixty hours would be a start—65 is what most people seem to be calling for. It is about getting a balance. We do not want to go back to the 80, 90 or 100-hour working week, but nor do we want to face the consequences of the 48 or 56-hour working week. There is a balance to be struck, and I would be very interested to hear what the Minister thinks can be done. This debate is obviously an interesting one because it can go down a European direction, which I know a Health Minister cannot say very much about today. However I would be interested to hear what he has to say about the NHS in his capacity as a Health Minister.
There is also the issue of bean counting. We must be very careful, because this debate is about delivering something to the patient and ensuring that the team around the patient, including the doctors, co-ordinate their work to meet the needs of the patient. If we get into very strict bean counting—whether we are talking about 48 hours, 60 hours or whatever—and do not recognise that this is about a patient-centred service, we will keep having more and more of these problems that we have discussed. That is the critical issue, and why we need the flexibility.
I entirely agree with the hon. Gentleman. Patient-led care is where we must get to. That is why we are all here; that is what the Health and Social Care Act 2012 will deliver. I am sure that we will all be working further to ensure that the patient is placed at the heart of the NHS.
Thank you, Mr Howarth, for calling me to speak. It is a pleasure to serve under you.
I congratulate Charlotte Leslie, who opened the debate, and the Backbench Business Committee on granting the debate. In fact, I want to pay a particular compliment to her for the comprehensive way in which she opened the debate and put forward her case.
Clearly, the working hours of all health workers, and not just junior doctors, are incredibly important to our NHS and to the quality of care that patients receive. I am glad that we have had a chance to examine those issues in some detail today in this Backbench Business Committee debate.
It is concerning that there have been reports in the press, and indeed from Members in Westminster Hall today and on other occasions, that there are cases where locum health workers have charged extortionate amounts for short-term cover in the NHS, with the potential knock-on effect on the quality of care that patients receive. As a number of hon. Members, including Ian Paisley, have said, that is a matter that is of particular concern, especially for small rural hospitals; that was a point that he made eloquently. It is an issue that I will explore in some detail later.
As we all know, the European working time directive is European Union legislation and it was enshrined in UK law as the Working Time Regulations 1998. Except for doctors in training and workers in certain excluded sectors, the directive has applied in full to most workers, including all employed doctors, since
Particular concerns arose in relation to the health and social care sector, and importantly in relation to the position of doctors, as well as junior doctors, who, since August 2004, were gradually brought within the provisions of the directive. From August 2004 to August 2009, junior doctors’ working hours gradually moved towards compliance with the 48-hour working week. Although junior doctors in some specialties could work a 52-hour week until
Of course, there have been particular concerns in relation to the health sector, and importantly regarding the position of doctors and junior doctors, which have led to this debate today. Although the directive applies to other sectors as well, it has always had a particular effect on the NHS, given how night-time and weekend cover has been organised in most hospitals, as we heard from Dr Poulter.
I note what several Members have said, particularly in relation to training. My hon. Friend Kate Hoey commented on Guy’s and St Thomas’ hospital, which is nationally and internationally renowned. The previous Labour Government commissioned the independent chair, Professor Sir John Temple, on behalf of NHS Medical Education England, to examine the impact of compliance with the directive on the quality of training. Dr Wollaston, who speaks on such matters with a great deal of experience, specifically referred to that. Although Sir John Temple’s 2010 report concluded that quality medical training can be delivered within a 48-hour working week, it also highlighted some challenges to be addressed, including round-the-clock team working. Those concerns have been echoed during today’s debate.
Other issues relating to the working times of doctors and junior doctors also need to be addressed. As Sir John Temple’s report found, there were concerns about post-graduate medical training, the objective of which is to produce fully qualified specialists who are able to provide high-quality, safe patient care. Experience of delivering services is an integral part of a junior doctor’s training. “Time for Training” highlighted some of the difficulties created for trainees and the service, especially in providing out-of-hours and weekend emergency patient care. Again, a number of Members have spoken about that today.
Some small, practical changes by employers, such as improving handovers and team-working at night, more involvement of doctors in designing their own working patterns, less reliance on junior doctors and more involvement of consultants during out-of-hours periods, have led to positive results without the need for excessive working hours. Clearly, issues remain, and I do not say that we have it right. Such matters should always be kept under review.
As I have said, the directive raises issues for health services across Europe, and Members have raised a number of concerns today about the directive’s impact on the NHS in the United Kingdom. We should consider ways to resolve those issues and be ready to work constructively with the European Commission and other member states to seek suitable solutions fit for our country’s needs.
As we know, the Commission is re-examining the directive. That is an acknowledgement that, although the legislation will remain, member states have had a number of issues with its implementation.
The hon. Gentleman will be aware that in 2008 the previous Labour Government attempted to make some changes to the working time directive. The European Commission started that process, but the European Parliament voted at that point to abolish altogether the opt-out on the 48-hour maximum working week. The previous Government quickly slammed the lid and ran away from any idea of reforming the working time directive. Does he think that that was a mistake and that the previous Government should have persevered with their original intention?
The previous Government were right to attempt to have the matter re-examined. Whether the previous Government’s acceptance of the ruling needs to be reconsidered is something we are discussing today. We have a new Government, of course, and they have a responsibility to take up such matters with European Union institutions, as I would expect a future Labour Government to have the same responsibility to pursue concerns raised by this Parliament. Of course, it is incumbent on the Government of the day to try to resolve such matters with EU institutions. I accept that, were there a Labour Government instead of the current coalition, it would be right for our Government—irrespective of which party is in control—to take up such matters with EU institutions.
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.
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.
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 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 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 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.
It is a pleasure to serve under your chairmanship this afternoon, Mr Howarth. I congratulate my hon. Friend 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 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 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 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 Kate Hoey, who cares passionately about this issue. My hon. Friend 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 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.
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?
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.
Does my right hon. Friend recognise that Sweden agreed legally to join the euro and has failed to do so, and so our inability to implement all our commitments might be seen by some as trivial in comparison?
My hon. Friend makes an interesting point that could tempt me, but I will not be tempted. Each member state of the European Union is answerable for its decisions and behaviour. I believe that if one is a member of an organisation and has signed up and committed oneself to certain procedures and legal ways to do business, it is only right that the British Government—
I will not, if my hon. Friend will forgive me, simply because I have only seven more minutes. I was hoping to address some of the points raised by my hon. Friend the Member for Bristol North West.
We have to abide by the legalities. Otherwise, chaos will ensue and we will not in the longer term achieve what we are hoping to, even if we might on that narrow issue. Until the negotiations in Europe come to a successful end we are obliged to comply with the European Court of Justice and we cannot unilaterally go against it. The Department of Health and the Department for Business, Innovation and Skills are working very closely together on how the WTD will apply to the UK health care sector. Both Departments agree that we need to keep the opt-out and it would be a grave error to surrender it or to abandon it for other concessions. That is a red line for us. We have to keep the opt-out.
We also want to solve the issue of flexible on-call time and compensatory rest that allows the NHS to work within the current constraints of the working time directive. Those are both very important issues to the Government and to the NHS, but as I said, the bottom line is that the opt-out must stay. European social partners have opened negotiations to amend the WTD. At this stage, as hon. Members will know, it is not national Governments directly who are conducting these negotiations; they are being done through what is known as the social partners. In our case, it is NHS Employers and the Local Government Association with regard to local government and the knock-on effect for social care; that is an important part of the delivery of NHS services and social care.
That process is autonomous, and operates independently of the Commission and Council. The social partners have nine months at most to reach an agreement. That takes us up to September 2012. If an agreement is reached, it would be submitted to the Council for approval. But if an agreement cannot be reached, it will be up to the Commission to issue a proposal to change the directive. The Government have made it patently clear to everyone that long-term, sustainable growth must be the EU’s key priority. Every decision the EU makes must be geared towards that. So we will carry on working with our partners to make sure that EU measures support labour market flexibility and do not impose unfair costs on member states or businesses, or services like the NHS, that could hold back our economy and the delivery of services.
For the NHS specifically we are keen to ensure that an amended directive provides more flexibility, particularly in the areas of on-call time and compensatory rest, provided that a workable opt-out can be maintained. Responding to concerns about how the directive is being applied, particularly with regard to medical training—an issue raised by a number of hon. Members—Medical Education England, the Government’s independent advisory body on medical education, commissioned an independent review chaired by Professor Sir John Temple. My right hon. Friend the Secretary of State for Health has asked Medical Education England to help improve our training practices in line with Sir John’s recommendations.
In response, Medical Education England has set up a programme known as Better Training Better Care, which will improve patient care by increasing the presence of consultants and by ensuring that service delivery supports training. It includes two important components: identifying, piloting, evaluating and sharing good education and training practice; and improving the curriculum so that training leads directly to safe, effective patient care. From an education and training perspective, handovers present an excellent opportunity for training. The Better Training Better Care programme includes pilots that will hopefully show how education and training practice can improve in that area and take advantage of those opportunities.
NHS trusts in England have responded very positively to this programme: 96 trusts applied for part of the £1 million available for NHS pilots in 2012-13. Following that competitive process, last month 16 projects with 16 NHS trusts were awarded funding for those pilots. I look forward to seeing what developments they come up with.
As I am running out of time, I say to my hon. Friend the Member for Bristol North West, who wants to make a contribution to end the debate, that I will write to her with answers to a number of important issues that she raised. However, I will deal briefly with two issues now.
First, my hon. Friend asked what will happen in emergency situations such as a flu pandemic. I hope I can give some reassurance on that point. In such circumstances, as long as health and safety are protected in the round and the employer has correctly judged that the circumstances are exceptional, the rest requirements of the directive can be suspended.
Secondly, my hon. Friend the Member for Kingswood and other Members raised the vital issue of locums, including the cost of locums and their number. I share the concern of my hon. Friends about the use of locums. They play an important role when there are short-term staff shortages, or when there is illness or holidays, and there may be a limited impact of the EWTD that means that trusts will be employing locums when they might not otherwise do so. However, the evidence about the extent of that practice is not as extensive and meaningful as we would like it to be; we would like to get a fuller picture. Nevertheless, whatever the reason for the use of locums, we are concerned across the board about their extensive use and the add-on costs that brings to the NHS. That is why we are working through our training programmes and through the Quality, Innovation, Productivity and Prevention programme to seek to minimise unnecessary use of locums and to bring down the number employed, thereby reducing costs. As I said to my hon. Friend the Member for Kingswood, there has been an 11% reduction in the employment of locums, and at the same time there has been an increase in doctors.
In conclusion, I also hope I can give some reassurance to my hon. Friends about staffing levels, particularly in specialised areas, because the situation is slightly more encouraging than they may have feared. For example, if we take the current year and general surgery—
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. 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 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 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 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 George Eustice.
I was encouraged that 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.
Sitting adjourned without Question put (