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The Netherlands' 1996 Working Time Act granted hospitals until 1 January 1999 to meet its requirements. In summer 1999, the health and safety inspectorate drew up an official report on nine hospitals that had still not properly arranged their schedules in line with the Act. The long working weeks of physicians' assistants raised special concern, partly due to the fact that their schedules are modelled on specialists' working weeks. Occupational disability amongst this category has risen dramatically over recent years, particularly due to emotional problems resulting from excessive on-the-job pressure. Preventive measures, including a more normal working week, are now under consideration.
The Working Time Act (Arbeidstijdenwet) which came into effect in January 1996, created a general framework for working time rules in the Netherlands, laying down regulations on normal working hours, rest periods and breaks, Sunday working, night work and overtime, while allowing flexibility through collective agreements or similar provisions. The law granted hospitals a three-year period of grace in order to implement new working and rest time schedules. The deadline passed in 1 January 1999 and in August 1999 the situation was still unresolved. In particular, physicians' assistants, who according to the law may not work more than 36 to 48 hours a week, are still working upwards of 60 hours a week, and 24-hour shifts are not uncommon. So far, the health and safety inspectorate has drawn up official reports on nine hospitals, which may receive fines of NLG 10,000 to NLG 15,000 per offence.
60 hours the norm
The National Physicians' Assistants Association (Landelijke Vereniging van Arts-Assistenten, LVAG) has spent years striving to introduce a normal, shorter working week for its members because, according to the LVAG chair, "working 70 hours a week is simply unhealthy." The association welcomed the potential sanctions for hospitals for violations of Working Time Act, but remains sceptical since previous agreements have had little effect on the actual situation of its members. According to LVAG, physicians' assistants are often treated as the final item on the budget, and their position is characterised by vulnerability and dependence. They face fierce competition for the few available training placements, and the supervising specialists who evaluate their performance do not want any complaints about working hours. Due to their dependent status, and because there is a high level of job satisfaction and their unpleasant schedule applies only for a limited number of years, physicians' assistants are said to tolerate a great deal. They often do not report their actual number of hours worked, and individuals who do follow the existing rules are compelled to report their problems to payroll accounting and, eventually, to the supervising specialist. As a result, an unfavourable evaluation may follow, according to reports from physicians' assistants.
The Dutch Hospitals Association (Nederlandse Vereniging van Ziekenhuizen, NVZ), which represents the employers, states that medical specialists also work long weeks and sees nothing wrong with the demanding schedule of physicians' assistants, which simply make up part of the healthcare employee culture. A long-standing assumption is that gruelling schedules help to create good physicians. Although NVZ admits that a limited number of hospitals are in violation of the rules, it argues that hospitals cannot comply with the Working Time Act's regulations because they are too complicated for implementation in the 24-hour care sector. Spokespersons for individual hospitals recognise the dramatic increase in work pressure arising from the fact that patients now require treatment for more complex problems, while the number of physicians' assistants has remained the same. As a result, the quality of the care provided suffers. NVZ endorses an expansion of training capacity and implores the government to allow hospitals time to change their culture. Hospitals not affiliated with a university have pointed out that they receive less funding for training than university-affiliated hospitals. They view physicians' assistants' long working weeks as a necessary evil, and see eliminating certain services such as emergency care during the night as the only possible solution to the problem.
The National Association of Physicians (Landelijke Vereniging van Artsen in Dienstverband, LAD) has met the position adopted by the hospitals and their representatives with scepticism. LAD argues that collective agreements for physicians have been largely ignored over the past years, with neither side observing them. LAD claims that hospitals currently attempt to elude regulations by using euphemisms such as "availability shifts" for night shifts, for example. LAD strongly recommends continuing critical evaluation of hospital practices.
Burn-out among specialists
The health and safety inspectorate's findings clearly indicate a dire situation, especially in the light of information recently released on the influx of new claimants of benefits under the Occupational Disability Insurance Act (WAO) in 1998 (NL9904133F): the number of recipients has risen again; the nature of complaints has changed; and a greater number of younger people are receiving benefits. Around half of benefit recipients aged under 35 in the healthcare sector, and a third of all recipients in the sector, are unable to work due to emotional problems. The number of medical specialists incapable of work due to "burn-out" symptoms is also increasing. Over the past five years, the total number of medical specialists receiving disability benefits has risen by 36%, and the number who stopped working on account of emotional problems has doubled. Severe on-the-job pressure is cited as the leading cause, and a survey has revealed that more than half the number of active specialists experience too much stress. Other contributing factors include waiting lists, insufficient budgets and stricter legislation in the healthcare sector.
This information surfaced when the company insuring physicians against disability teetered on the edge of bankruptcy. A bank takeover saved the company from going under, but the scare provided the impetus for an investigation of the significantly increase in occupational disability and for preventive measures, which so far include a 24-hour telephone help-desk and classes on how avoid burn-out.
Commentary
Although the Netherlands has the highest labour productivity in Europe, the number of hours worked annually is among the lowest. In commercial sectors, work pressure is connected to ever-increasing competition, but the same cannot be said for the healthcare sector, where mounting pressure stems from the combination of demographic developments - such as fewer births and an ageing population - with relative cutbacks in care. The increasing number of disability benefit recipients, coupled with the relatively high sickness absence rate in the health care sector, send out increasingly loud signals that can no longer be ignored by politicians and other relevant parties (such as insurers), and also indicate that it is not possible to implement the Working Time Act in isolation from the broader picture. (Marianne Grünell, HSI)