Editorial The New Deal – a poor deal for service and training? Our School of Anaesthesia has recently been struggling with the hours implica- tions of the ‘New Deal’ (HSC 1998/ 240) for trainee doctors, with wide- spread rewriting of job plans for the majority of trainees in order to achieve accreditation. This has proven taxing for most service organisers. Diary studies of hours have been undertaken, and strate- gies developed to meet the new require- ments, with the potential to affect doctors’ working conditions and train- ing drastically. As trainee representatives in our region, it is readily apparent to us that very few trainees are looking for- ward to the expected change from the rota system to full, or partial, shift work- ing patterns. However, we are well aware that the main agenda of the ‘new deal’ may no longer be the well being of trainee doctors, and that protection of patients from overtired doctors has also entered the equation. We would like briefly to examine these two main aims of the enforced drive to reduction in working hours. Considering the trainees’ perspective, a straw poll in our area would suggest that any form of shift work would be unpop- ular. Various studies have shown that where shifts and partial shifts have been introduced following a rota system, they have been found to be less satisfactory for the trainees, from both a personal and a professional point of view [1–4]. More importantly, many of these doctors felt that their training experience was adversely affected by a change to shift work. If the training of doctors is adversely affected in this way, presumably some other improvement in patient care offsets this, perhaps leading to greater patient safety and satisfaction. It cannot be disputed that tired doctors will per- form their duties less well, but perfor- mance is also influenced by other factors such as a feeling of being valued, know- ing the patients well and a sense of having made a difference to a patient’s care. Regarding patient safety and protec- tion from overworked doctors, a change to partial shift work may not always be associated with the reduction in hours that might have been anticipated; doc- tors will continue to work in excess of contracted hours in order to provide service commitment [2]. In a crossover study between partial shifts and an on- call rota, patient care was of an equally high standard under both systems, and when patients were questioned, they found both systems acceptable [4]. The trainee doctors, however, although apparently not exhausted and perform- ing inadequately whilst working an on- call system, found the partial shifts led to demoralisation and disruption in the working of the unit. Partial shift work also adversely affects continuity of care [2], with consequent effects on training and job satisfaction. If continuity of care, training and morale of hospital doctors may be adversely affected by these work- ing patterns, but fatigue is not reduced, how can this lead to improvement in patient care? In our region, and we suspect most others, we have for many years had a system of ‘post on-call periods’ where the trainee anaesthetist goes home after a night on-call. This satisfies the trainee’s wish to work an on-call rota, and cer- tainly protects patients from a tired ‘post on-call’ doctor. It would appear to be an ideal situation for all concerned. Super- ficially it appears to fit into the descrip- tion of a 24-h partial shift provided the trainees are getting 4 h continuous rest 75% of the time. However, there are two problems: some busy on-call sectors may not satisfy this requirement for rest during the night, and according to the new deal, 24 h is 24 h and not a minute longer, leaving no time for handover, which is normally required in all areas of anaesthetic practice. A change to some form of shift work in certain sectors would seem inevitable; however, in qui- eter areas we feel that such changes would be a retrograde step. We presume that strict adherence to the ‘24-h only’ rule aims to protect trainees in some specialities from long-lasting handovers, which can sometimes go on into the afternoon. In anaesthesia, this type of ward round does not occur and such a stringent 24-h rule is not necessary. By simply allowing an extra 30-min period for a rapid business handover round, many far reaching and unwanted changes could be avoided. What concerns our trainees is that in changing from what appears to be a perfectly adequate arrangement, ‘the deal’ for trainees and patients should be at least maintained or, better still, improved. Without an expansion of trainee numbers, which in fact are being reduced, it is hard to envisage trainees being able to continue to provide the same service commitment they cur- rently do. An option would be to allow senior, nonresident training modules to disappear and become incorporated into the resident ones, expanding the num- bers to produce workable shifts. Many would argue this would have important consequences for the senior trainee approaching consultancy. Staff-grade doctors might expand numbers, but local experience would suggest their availability is limited, although we have not been able to confirm this nationally. In many respects it will often be inap- propriate to attempt to appoint a non- consultant career-grade doctor to many areas in which trainee anaesthetists work. Does this leave consultants to pick up the short fall? We suspect ‘Clin- ical Governance’ would suggest it does, but where are the extra consultants to come from when national training num- bers are being reduced? Importantly, of course, this is intended to be a cost- neutral exercise! With further reduction of total weekly hours, but the same out-of- hours work to cover, can standards of training be maintained? Experience in other specialities suggests it may not be, and prompted the authors of one paper to suggest the further implementation of Anaesthesia, 2000, 55, pages 206–207 ................................................................................................................................................................................................................................................ 206  2000 Blackwell Science Ltd