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Brian Edwards CBE
Emeritus Professor of Healthcare Development
University of Sheffield
The arguments about the application of the European Working Time directive in the health sector continue. Most accept the need to limit working hours, rules for which are long established in the haulage and airline industries. However, they do not sit comfortably with working and training practices in the health sector. Although the directive impacts on all disciplines, including pharmacy, the problem is at its most severe for doctors in training who work traditionally long hours and are regularly on-call to deal with emergencies. What turned an operational problem into a potential crisis was the European Court of Justice’s interpretation of the directive. They decided that working time should include on-call time, even if in practice the employee concerned was not called out. The Court also ruled that compensatory rest should be taken immediately, making it impossible for doctors who are called out to be on duty the following day.
All over Europe, governments have been renegotiating junior doctor rotas, switching responsibilities to other professions to reduce the intensity of work, and contemplating the need to expand the medical labour force rapidly. The financial implications for some countries are enormous. The directive does not apply to doctors or pharmacists who work independently or contract their services, who will continue to work long and sometimes dangerous hours. Governments do want safe working practices, but without the cost and disruption that this directive is generating. The health professions are divided on the issue, with surgeons being particularly worried about the impact on training if hours of practice are reduced.
The Commission has been under pressure to change the directive and has just finished a consultation period about the next steps. Most objectors want to redefine the on-call judgement so that inactive resident time spent on-call does not count, although it could of course still be paid for as a standby fee. Stretching the rules about compensatory time off from immediate to within an agreed period of time would also help. Once again, the health sector is caught up in a directive designed for the general economy and not sufficiently adapted to its special needs.
The enlargement process is also generating employment challenges, as most of the established members put up temporary barriers to professional migration. Only Ireland, Denmark and the UK have elected not to use the two-year transitional arrangements, although the UK has introduced work permit rules and changed its eligibility criteria for social benefits. All these transitional arrangements will achieve is to delay the impact of the problem. Many health professionals will want to migrate to the wealthy countries because of better income, training and career opportunities. Given the principle of free movement, it is difficult to see how these evacuations can be stopped. But the traffic is not just in one direction. Venture capitalists are heavily investing in specialist hospital services in countries such as Poland because they can see an upsurge in demand in the accession countries. These centres will require highly trained staff. In any case, as the economic gaps between member countries narrow, the migration pressures should ease. The problem will then focus in particular on the countries in Eastern Europe who are not members of the EU.
Small steps often have significant long-term consequences, and a recent example of this is the decision to put into operation the first set of EU Health Indicators. First will come work on tighter definitions to ensure the product is reliable. It will then be possible to make at least tentative judgements about the effectiveness of national health systems and the return they generate on investment. Given the crucial role the health industry plays in most national economies, this is not an unreasonable step unless you are suspicious that this might lead to far greater Commission involvement in health. It will and perhaps it should.