Implementation of the European Working Time Directive in an NHS trust: impact on patient care and junior doctor welfare

Discussion

With 58 full-time junior medical doctors at the hospital between 2006 and 2007, the rotas necessary to comply with the introduction of EWTD resulted in a loss of at least 348 working hours each week, the equivalent of seven whole-time posts. Night shifts were reduced from a seven-day block, which may reduce performance, to periods of three and four nights on-call.⁶

Patient care (as measured by in-hospital mortality and length of stay) was not affected by these changes to working practice. The percentage of inpatients who died in hospital fell slightly but their median length of stay was unchanged. There was a small rise in readmissions.

During the study period, episodes of sick leave among junior doctors more than doubled with just over 1 in 3 taking leave in the year to August 2007 and nearly 3 in 4 the following year. The number of days taken and the number of repeated episodes of leave increased.

Reliable comparative adjusted data for admissions and length of stay for non-elective medical admissions could not be found. Fifty per cent of patients in the current study were over 75 years of age, which compares with a value of approximately 25% given in the Hospital Episode Statistics (HES) for 2006–7.⁷ The hospital standardised mortality ratio (2002–5) for the two local primary care trusts was 90.9 and 98.0 suggesting that the observed in-hospital mortality is unexceptional.⁸ Local length of stay is higher than for national comparator sites but equivalent to those areas with similarly elderly populations.⁹

To facilitate an even distribution of junior doctor workload, inpatient care was also partially reorganised, from an age-related (cut-off 75 year) to a ward-based system. This had no apparent effect on patient outcome.

Readmissions comprised nearly one quarter of all admissions. Although seemingly high, reported rates in other adult populations vary from 5% to 29%.¹⁰ The NHS Information Centre reported a 22% increase in readmissions within 28 days (in patients aged 16–75 years in all specialties) to 8.6 per 100 discharges, from 1998 to 2006. For patients over the age of 75 there was a 31% increase in readmissions to 13.6 per 100 discharges over the same period, a rate similar to our findings.¹¹

Longer working hours and extended work shifts are reported to adversely influence junior doctor performance with shorter hours associated with less serious medical errors.^12–14 However, the authors are not aware of any literature on the relationship between working practice and sickness in medical trainees. In factory employees, the number of sick days during the preceding six months was related to psychosomatic wellbeing, while a review of sickness in non-medical literature identified several recurrent factors.¹⁵ These included repeated absences, poor working conditions, lack of group cohesiveness, organisational behaviour and job satisfaction, use of abilities and responsibility and ‘marketplace conditions’.¹⁶

Most, if not all, of these factors may apply to medical trainees. Changes to both the organisation of care and medical training have recently occurred. In addition to the increasing emphasis on reduced length of stay on medical wards, the system of application for training has been restructured and trainee hours reduced. Both shift work and reduced working hours may contribute to a loss of the ‘group cohesiveness’ provided by the traditional medical team. These factors may exert a cumulative effect although only a tightening of the existing shift rotas, and a rearrangement of ward working specifically separate the years studied. The rotas necessary to comply with the directive reduced the numbers of doctors available on the wards at any one time, thus rising sickness levels have a proportionately greater effect on working hours lost. This is compounded by difficulties in arranging locum cover and the shortfall in trainee recruitment that has occurred in some areas.

Sick leave was chosen as a measure of junior doctor welfare due to a comprehensive internal system of paper records of self-and externally certified sick leave. Although sick leave may be a weak index of trainee welfare, a more robust indicator is lacking. The pattern of leave appeared not to change, insofar as the number of days taken per episode was relatively constant, suggesting that alterations to working practice affected frequency as opposed to type of absence. While it might be expected that the burden of the reduction in hours might fall upon new trainees, the increase in sick leave was seen across all grades (Fig 1). This would also suggest a generic effect and response; not only does the loss of hours impact upon all trainees, but the response to this demand was not driven by a differing work ethic between new and more experienced trainees. It might also suggest that more senior trainees may be taking on roles previously performed by more junior grades. Finally it is salutary to note that in the space of one calendar year the average age of patients rose significantly, with an increasing number of female admissions. There are considerable implications for healthcare planning if such trends are sustained.

• Download figure
• Open in new tab
• Download powerpoint

Fig 1.

The total number of episodes of sick leave taken, by grade, for the period August 2006–July 2007 and August 2007–July 2008. HO ? house officer; REG ? registrar; SHO ? senior house officer.

There are several limitations to this study. All patient data were extracted from the patient information system and are thus subject to the constraints of the reliability of that system. Assuming no systematic error in the local information system, the large numbers contained should, however, serve to minimise any errors in patient data. The study is a retrospective observational analysis and reflects the impact of working patterns implemented at a single site and may not be representative of other areas. Prospective data from several sites would be required to confirm the findings presented here. Data on sick leave were collected from paper forms submitted by the trainee. Underreporting is possible but unlikely to be significant since rigorous efforts were made to ensure adequate levels. Changes to the recruitment, training and working practices of junior doctors may have confounded the findings.