03/02/05 The European Working Time Directive effect on Junior Doctor Attrition from the British National Health Service UK System Dynamics Society 7th Annual Gathering Dr Mark Ratnarajah
Introduction Is there a ‘Doctor in the House’?
Personal Profile Dr Mark Ratnarajah Paediatric Specialist Registrar - London Executive MBA student- London Business School
What is my interest in the issue? Physician with 9 years experience working in the NHS Management Report - London Business School Application of a robust simulation tool to an important National Health Service issue
The National Health Service
The National Health Service
The National Health Service “a great patchwork, a good deal of good intentions, a great deal of inadequacies”. The Rt Hon Jennie Lee MP, Minister of State, Department of Education and Science (Aneurin Bevan’s widow )
The National Health Service Aneurin Bevan, Minister for Health 1945-48
The National Health Service- A Sea change in Societal attitudes Litigious Culture Consultant delivered vs led Service Service vs Educational provision
The National Health Service- A Sea change in Societal attitudes Consultant Remuneration and Private Practice Patient Charter Life Style and Family considerations
European Union Working Time Directive
Relevance of the EUWTD to Junior Doctors Previously junior doctors in training were exempt from the EUWTD • recognition of the need for continuity of service provision 1 In May 2000 • decision was changed to included junior doctors within the directive 2 1 Article 1(3) of the Working Time Directive (93/104/EC) 2 Amendment to Article 17(2.1) DIRECTIVE 2000/34/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 22 June 2000, amending Council Directive 93/104/EC concerning certain aspects of the organisation of working time to cover sectors and activities excluded from that Directive
The European Union Working Time Directive EU Working Time Directive 2003 2004 2007 2009 ‘New Deal’ 72 Hours 58 Hours 56 Hours 48 Hours Max. 56 Hours Maximum 13 Hours continuous cont. Working Working Period Period (Minimum 11 Hours rest/24 hours period)
Purpose of the EUWTD Limit Junior Doctors working hours Health and Safety legislation Risk Mitigation
Attitudes towards the EUWTD- A puzzling Dynamic Approximately 74% of medical specialist registrars were opposed to the change 3 : • Training • Work-life balance • Levels of pay 3 Implementation of the European Working Time Directive by August 2004 for specialist registrars in acute hospital medicine, Royal College of Physicians commentary, supplement 1, 2003
Workforce consequences of the EUWTD The EUWTD presents a major challenge to NHS hospitals to implement Currently there are insufficient junior doctors to cover a full shift system 4 Growing discontentment amongst junior doctors 4 Hospital doctors- The European Working Time Directive, May 2004, British Medical Association
Current NHS working patterns Source: Staffing levels in acute medicine in January 2004- the lead-up to the EUWTD, April 2004, Royal College of Physicians
Workforce consequences of the EUWTD Workforce requirements 58 Hours/ week 48 Hours/ week 3000 doctor 208,296 - 476,638 hours/week doctor hours/ week 3,700 junior 4,300 - 9,900 junior doctors doctors
New Registered Doctors in the UK by country of qualification 12000 10000 UK 8000 EU excluding UK 6000 Non EU 4000 Total 2000 0 1989 1998 2000 2002
A System Dynamics Approach
Why use a computer model? Represent medical workforce dynamics in the UK • describe a compelling story • model this puzzling dynamic Sensitivity analyses of policy and parameter changes
Where was data sourced? Published Medical Workforce research Government Healthcare policies European Union Directives Professional Experience
What has System Dynamics to do with the NHS? Quantitative Assets: People- Workforce Time- Duration of training Pay- Remuneration Qualitative Assets: Beliefs/ attitudes- Morale Service Level- Quality of Patient Care Quality of Life- Work-Life Balance
System Dynamics: Application
Overview Model Effect of European Working Time DIrective (EUWTD) on Wrokforce Work Life Balance EUWTD Rota Flexibility Rumuneration EUWTD EUWTD Training Duration EUWTD Quality of Patient Morale Care EUWTD Junior Doctor Attrition Junior Doctor Medical School Training Recruitment EUWTD Junior Doctors Workforce deficit Work Visa Expiry Recruitment Non UK Doctors Target Workforce EUWTD
Base Case Model A simplified representation of a dynamically complex world that is recognisable to medical practioners….but with one important ingredient missing.
Medical Workforce Planning Annual f ractional Rate of loss to NonHospital Annual Attrition Non Hospital Junior Doctor Appointments Fraction Appointments Attrition Duration of Medical School Training Rate of Rate of Junior Doctor Specialist Doctor Medical Students Training Retirement Rate of Rate of Specialist Junior Medical Student Medical Student Doctors Doctors Recruitment Training Duration of Traditional Working Visa Time to Duration of Recruit Specialist Training Non UK Resident Doctors Duration of Specialist Training Non UK Resident Relativ e Non UK Resident Doctor Attrition Doctor Duration Recruitment rate of Training Duration of Percentage of Training under EUWTD Workf orce Compliant Rota Compliant with EUWTD Time interv al Workf orce to EUWTD Def icit amendment Target EUWTD Compliant Workf orce
Quality of Patient Care Percentage of Workf orce Proportional Compliant with increase in EUWTD Handov ers Actual Error Rate EUWTD shif ts per week Relativ e Error rate Pre EUWTD On call Shif ts per Week Expected Error Rate Quality of Patient Care Junior Doctors Patient Doctor Actual Work Ratio Schedule Pressure Non UK Resident Relativ e Doctors Work schedule Pressure Expected Patient Waiting time Change in daily admissions PreEUWTD Patient Doctor ratio Patient admissions Expected Annual Growth f raction Work schedule in Hospital Admissions Pressure
Workforce Remuneration Banding Multiplier Percentage of f or Non EUWTD Compliant Workf orce Aggregate Rota Compliant with Pay discrepancy EUWTD on Morale Ov ertime Multiplier Banding Multiplier f or EUWTD Compliant Rota Junior doctor's Annual base salary Pay Change Junior doctor's salary Change in Future Pay earnings Comparison Current Change in Pay Comparison comparativ e earnings Annual Comparativ e Pay Av erage Annual Pay Change Comparativ e Av erage Annual Earnings Growth Future Salary Comparativ e Future Comparativ e Expectation Salary Expectation Earnings Growth Change in Change in Comparativ e Future Salary Future Salary
Work/ Life Balance Time interv al Workf orce Rota to EUWTD Planning Delay amendment Av erage Non EUWTD Compliant Rota Percentage of Workf orce Compliant with EUWTD EU Compliant Rota EU Compliant Shif t Duration Hours worked per week Av erage Non EU Compliant Length Shif t Duration of Shif t Socially Adv antageous Hours per week Work Lif e Balance Av erage Relativ e Shif ts per Week Work Lif e Balance Expected Work Lif e Balance Pre EUWTD on call shif ts per week Flexibility of Rota
The Complete Model ….the missing ingredient!
Morale Morale is considered an integral part of the junior doctor’s decision making process Stock of morale Determinants of Morale
Morale Relativ e Work Lif e Balance Flexibility of Rota Relativ e Duration of Training Aggregate Quality of Pay discrepancy Patient Care on Morale Indicated Morale Change in Morale Morale Time to change Morale
Workforce Base case- a reminder Annual f ractional Rate of loss to NonHospital Non Hospital Junior Doctor Appointments Appointments Attrition Annual Attrition Duration of Fraction Medical School Training Rate of Rate of Junior Doctor Specialist Doctor Medical Students Training Retirement Rate of Rate of Specialist Junior Medical Student Medical Student Doctors Doctors Training Recruitment
Base case + Morale = Complete case Annual f ractional Morale Rate of loss to NonHospital Non Hospital Junior Doctor Appointments Appointments Attrition Annual Attrition Duration of Fraction Medical School Training Rate of Rate of Junior Doctor Specialist Doctor Medical Students Training Retirement Rate of Rate of Specialist Junior Medical Student Medical Student Doctors Doctors Training Recruitment
List of Simulations Quality of Patient Care • Patient/ doctor ratio • Error Rate Workforce dynamics • Base case • Complete case Stock of Morale Duration of Specialist Doctor Training Work/ Life Balance Work Flexibility Doctor Remuneration
List of Simulations Quality of Patient Care • Patient/ doctor ratio • Error Rate Workforce dynamics • Base case • Complete case Stock of Morale Duration of Specialist Doctor Training Work/ Life Balance Work Flexibility Doctor Remuneration
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