Temple report summary: Time for change

Temple report- Time for Training: A Review of the impact of the European Working Time Directive on the quality of training
The report Time for Training was commissioned by Medical Education England at the request of the former secretary of state for health Alan Johnson. The report was instigated in response to the concern raised by many specialties, but by surgeons in particular, that after the introduction of the EWTD it was impossible to ensure doctors in training acquired a sufficient number of hours of supervised and hands-on experience to bring them up to an adequate standard. The report was published on June 9, 2010
The report looked at the impact of the 48-hour week on the quality of the training that is necessary to ensure the continuing supply of a world class workforce which is able to deliver high quality services to patients.

Problems with EWTD implementation:
• The reduced hours have necessitated a move to shift patterns of work in many
Specialties (Any doctor working to a rota that requires them to work different duty times at certain points on the rota can be considered to be a shift worker). Shift working has decreased training opportunities and impacted on trainee experience by reduction in trainer and trainee interaction and lack of continuity of patient care. Although with the reduction in hours there should be less sleep deprivation and better work–life balance for trainees, but shift patterns have possibly decreased the quality of life, as work periods, although shorter, are more frequent, less regular and more antisocial.
• The move to resident shift systems to accommodate the 48-hour week means that more trainee doctors are required to cover the out of hours care if the structure of service cover remains the same. This increased requirement for doctors results in an increase in the number of rota gaps. Recruitment challenges due to changes in immigration law have compounded the difficulty in fillings gaps. Rota gaps result in trainees being moved from their daytime, more elective training often at very short notice to fill service gaps. These are usually out of hours where there is minimal supervision and therefore less training opportunity. This results in the trainee missing out on the planned training that day and often the next due to compensatory rest. Although many rotas are compliant with 48 hours on paper, rotas have gaps.
• Rigid, poorly designed rotas result in trainees being unsupported and unsupervised.
• The impact of EWTD is greatest in specialties with high emergency and/or out of hours workloads

Recommendations
The report recommends that high quality training can be delivered in 48 hours. Any current problems will not be solved by either increasing hours or lengthening training programmes, says the report, which shows that despite an increase in consultant numbers of more than 60% over the past ten years, hospitals remain too reliant on junior doctors to provide out of hours services. There is a total of over 15,000 hours available to trainees working a 48-hour week in a seven-year training programme, but these are not all being used effectively for training.

It recommends the following to achieve high quality training within EWTD:
Implement a consultant delivered service: Consultants must be more directly responsible for the delivery of 24/7 care. The roles of consultants need to be developed for them to be more directly involved in out of hours care.

Service delivery must explicitly support training: Services must be designed and configured to deliver high quality patient care and training. Reconfiguration or redesign of elective and emergency services and an effective Hospital at Night programme are two of the ways in which healthcare can be changed to support training and safe services

Make every moment count
• Training must be planned and focused for the trainees’ needs
• Trainers and trainees must use the learning opportunities in every clinical situation
• Handovers can be an effective learning experience when supervised by senior staff, preferably consultants
• The co-ordinated, integrated use of simulation and technology can provide a safe, controlled environment and accelerate learning

Recognise, develop and reward trainers
Consultants formally and directly involved in training should be identified. • They must be trained, accredited and supported.

Training excellence requires regular planning and monitoring
Commissioner levers should be strengthened to incentivise training, ensure accountability and reward high quality and innovation

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