Directive effect on Junior Doctor Attrition from the British - - PowerPoint PPT Presentation

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Directive effect on Junior Doctor Attrition from the British - - PowerPoint PPT Presentation

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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?

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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

03/02/05

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Introduction

Is there a ‘Doctor in the House’?

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Personal Profile

Dr Mark Ratnarajah

 Paediatric Specialist Registrar - London  Executive MBA student- London Business

School

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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

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The National Health Service

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The National Health Service

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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)

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The National Health Service

Aneurin Bevan, Minister for Health 1945-48

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The National Health Service- A Sea change in Societal attitudes

 Litigious Culture  Consultant delivered vs led Service  Service vs Educational provision

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The National Health Service- A Sea change in Societal attitudes

 Consultant Remuneration

and Private Practice

 Patient Charter  Life Style and Family considerations

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European Union Working Time Directive

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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 provision1

 In May 2000

  • decision was changed to included junior

doctors within the directive2

1Article 1(3) of the Working Time Directive (93/104/EC) 2Amendment 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

  • rganisation of working time to cover sectors and activities excluded from that Directive
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The European Union Working Time Directive

EU Working Time Directive

2003 ‘New Deal’ 2004 2007 2009 72 Hours 58 Hours 56 Hours 48 Hours

  • Max. 56 Hours
  • cont. Working

Period Maximum 13 Hours continuous Working Period (Minimum 11 Hours rest/24 hours period)

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Purpose of the EUWTD

 Limit Junior Doctors working hours  Health and Safety legislation  Risk Mitigation

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Attitudes towards the EUWTD- A puzzling Dynamic

 Approximately 74% of medical specialist

registrars were opposed to the change3:

  • Training
  • Work-life balance
  • Levels of pay

3Implementation of the European Working Time Directive by August 2004 for specialist registrars in acute hospital medicine, Royal College of Physicians commentary, supplement 1, 2003

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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

4Hospital doctors- The European Working Time Directive, May 2004, British Medical Association

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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

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Workforce consequences of the EUWTD

Workforce requirements

58 Hours/ week 48 Hours/ week 3000 doctor hours/week 208,296 - 476,638 doctor hours/ week 3,700 junior doctors 4,300 - 9,900 junior doctors

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New Registered Doctors in the UK by country of qualification

2000 4000 6000 8000 10000 12000 1989 1998 2000 2002 UK EU excluding UK Non EU Total

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A System Dynamics Approach

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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

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Where was data sourced?

 Published Medical Workforce research  Government Healthcare policies  European Union Directives  Professional Experience

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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

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System Dynamics: Application

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Overview Model

Junior Doctors Medical School Recruitment Junior Doctor Training EUWTD Non UK Doctors Work Visa Expiry Junior Doctor Attrition Morale Target Workforce EUWTD Rota Flexibility EUWTD Work Life Balance EUWTD Rumuneration EUWTD Training Duration EUWTD Quality of Patient Care EUWTD Recruitment Workforce deficit Effect of European Working Time DIrective (EUWTD) on Wrokforce

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Base Case Model

A simplified representation of a dynamically complex world that is recognisable to medical practioners….but with one important ingredient missing.

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Medical Workforce Planning

Medical Students Junior Doctors Specialist Doctors Rate of Medical Student Recruitment Rate of Medical Student Training Rate of Junior Doctor Training Rate of Specialist Doctor Retirement Rate of Non Hospital Appointments Junior Doctor Attrition Annual f ractional loss to NonHospital Appointments Annual Attrition Fraction Duration of Medical School Training Time to Recruit Workf orce Def icit Non UK Resident Doctors Non UK Resident Doctor Recruitment rate Non UK Resident Doctor Attrition Duration of Working Visa Target EUWTD Compliant Workf orce Time interv al to EUWTD amendment Duration of Specialist Training Duration of Training under EUWTD Compliant Rota Percentage of Workf orce Compliant with EUWTD Traditional Duration of Specialist Training Relativ e Duration

  • f Training
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Actual Work Schedule Pressure Expected Work schedule Pressure Quality of Patient Care PreEUWTD Patient Doctor ratio Non UK Resident Doctors Junior Doctors Patient admissions Patient Doctor Ratio Change in daily admissions Relativ e Work schedule Pressure Annual Growth f raction in Hospital Admissions Expected Patient Waiting time Relativ e Error rate Expected Error Rate Percentage of Workf orce Compliant with EUWTD EUWTD shif ts per week Actual Error Rate Proportional increase in Handov ers Pre EUWTD On call Shif ts per Week

Quality of Patient Care

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Workforce Remuneration

Junior doctor's salary Percentage of Workf orce Compliant with EUWTD Annual Pay Change Current Pay Comparison Change in comparativ e earnings Aggregate Pay discrepancy

  • n Morale

Banding Multiplier f or EUWTD Compliant Rota Banding Multiplier f or Non EUWTD Compliant Rota Ov ertime Multiplier Av erage Annual Comparativ e Earnings Growth Comparativ e Pay Junior doctor's base salary Change in earnings Future Salary Expectation Change in Future Salary Comparativ e Future Salary Expectation Change in Comparativ e Future Salary Av erage Annual Comparativ e Earnings Growth Annual Pay Change Future Pay Comparison

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Percentage of Workf orce Compliant with EUWTD Hours worked per week EU Compliant Rota Av erage Non EUWTD Compliant Rota Time interv al to EUWTD amendment Length

  • f Shif t

Av erage Shif ts per Week EU Compliant Shif t Duration Av erage Non EU Compliant Shif t Duration Workf orce Rota Planning Delay Flexibility

  • f Rota

Socially Adv antageous Hours per week Work Lif e Balance Relativ e Work Lif e Balance Expected Work Lif e Balance Pre EUWTD

  • n call shif ts per week

Work/ Life Balance

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The Complete Model

….the missing ingredient!

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Morale

 Morale is considered an integral part of the

junior doctor’s decision making process

 Stock of morale  Determinants of Morale

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Morale

Relativ e Duration

  • f Training

Indicated Morale Flexibility

  • f Rota

Morale Change in Morale Quality of Patient Care Relativ e Work Lif e Balance Aggregate Pay discrepancy

  • n Morale

Time to change Morale

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Workforce Base case- a reminder

Medical Students Junior Doctors Specialist Doctors Rate of Medical Student Recruitment Rate of Medical Student Training Rate of Junior Doctor Training Rate of Specialist Doctor Retirement Rate of Non Hospital Appointments Junior Doctor Attrition Annual f ractional loss to NonHospital Appointments Annual Attrition Fraction Duration of Medical School Training

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Base case + Morale = Complete case

Medical Students Junior Doctors Specialist Doctors Rate of Medical Student Recruitment Rate of Medical Student Training Rate of Junior Doctor Training Rate of Specialist Doctor Retirement Rate of Non Hospital Appointments Junior Doctor Attrition Annual f ractional loss to NonHospital Appointments Annual Attrition Fraction Morale Duration of Medical School Training

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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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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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Simulation: Base Case Model

  • Quality of Patient Care
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Patient Admissions

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Patient/ Doctor Ratio

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Quality of Patient Care

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Simulation: Base Case Model

  • Workforce Dynamics
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Workforce Dynamics- base case

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Workforce Dynamics- base case

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Simulation: Complete Case

  • Workforce Dynamics
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Erosion of Morale

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Workforce Dynamics- base case a quick reminder

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Workforce Dynamics- Complete Case

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Workforce Dynamics- Complete Case

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Sensitivity Analysis

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Sensitivity Analysis

 Parameter changes

  • Time to change level of Morale on

– Stock of Morale – Workforce Dynamics  Policy changes

  • Time until EUWTD Amendment on

– Workforce Dynamics – Quality of Patient Care

  • Medical School Recruitment Rate on

– Workforce Dynamics

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Simulation: Scenario Analysis- Parameter changes

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Parameter change- Time to change Morale

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Parameter change- Time to change Morale

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Simulation: Scenario Analysis- Policy changes

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Policy Change- Time until EUWTD amendment change

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Policy Change- Medical School Recruitment Rate

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Conclusions

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Base Case Model (without Morale)

 In the long term

  • Target level of junior doctors can be

sustained

  • Patient/ Doctor ratio will continue to

increase

 In the short term

  • Non-UK trained doctors serve to fill the

deficit

 Assumption

  • Junior doctors are resilient to the effects
  • f policy changes
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The Complete Model

The EUWTD has the effect of:

 Reducing junior doctor morale  Increasing junior doctor attrition rate due to:

  • Falling quality of patient care
  • Decline in work-life balance
  • Decline work flexibility
  • Increased duration of training

(Rather than over pay discrepancies)

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The Complete Model

The EUWTD has the effect of:

 Relying on Non-UK trained doctors to

make up the Workforce shortfall

 Eventually impacting on the numbers of

Consultants in the NHS

  • If no other corrective changes are made
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Future Considerations

 To Model the effects of :

 Flexible training for Junior Doctors  Increase in proportion of Female doctors  Consultants impact on training of junior doctors

and quality of patient care

  • Consideration of Resident Consultants

 Reduction in University resources to Medical

schools despite expansion of Medical student intake

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Future Considerations

 This is a work in progress  Need to collaborate with Department of

Health Policy makers and other stakeholders

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Questions

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markratnarajah1@mac.com