European Working Time Directive (2)

In preparing our manuscript we found little formal research into junior doctor welfare. It seems paradoxical that the European Working Time Directive (EWTD) sought to improve this measure without a clear understanding of how this might best be attained. In the face of constant demand, a reduction in trainee hours without increase in numbers permits four scenarios that allow medical care to continue safely. The first is that prior to the reduction in hours there was large inefficiency (>10%). This has not, to our knowledge, been demonstrated. If such inefficiency were not present then, as Medford suggests, either work is being redistributed, omitted or compressed. Significant redistribution of medical work would be needed to cover the loss of nearly one seventh of the medical workforce. While nursing sickness rose during the period covering the introduction of the 48-hour week this finding is confounded by simultaneous alteration to bank staff remuneration which resulted in lesser bank usage. We do not have accurate data on consultant sick leave. Our finding that inpatient mortality and duration of hospital admission were not compromised supports the interpretation that work was not omitted. We may then speculate that work compression and task density must have increased. This effect will be amplified, as we indicated, with higher rates of sickness in a smaller group of trainees. Medford notes that the measurement of work compression and the impact of such compression upon trainees is difficult to assess, however, we found significant psychological stress in two of 15 trainees in a small (non-validated and unpublished) follow-up study. This merits further research.

We welcome the comments of Tucker and Folkar and note their contention that it is not the reduction in hours per se but the response of the employer, through rota design, that may be responsible for any negative effects. Underpinning this conclusion must be the fundamental assumption that that the same workload can safely be achieved, for both patients and staff, with reduced hours and less staff. Little guidance was available in meeting the 48-hour limit. We agree that enhanced rota design might improve the impact of EWTD implementation, but note that the authors refer to the ‘likely (our italics) impact of EWTD-compliant work schedules’. We are thus unclear if they were able to show that it is possible, without increasing staff numbers, to construct such a rota, meet full EWTD compliance and maintain workload and safe patient outcome? We would thus be concerned if attention were prematurely drawn away from the reduction in hours towards the responsibilities of the employer. We acknowledge that there are many uncertainties. Although our study has obvious limitations we sought to be as objective as possible in an attempt to lessen the speculation of ourselves and others. Contrary to the expectation of some, we did not find a reduction in standards of care. We did, however, find that sickness among trainees was markedly increased. This requires explanation. Surely trainees deserve more formal assessment of alternative ways of providing safe patient care while meeting EWTD compliance before it can be confidently stated that a working week of 48 hours is good for their welfare and training? We would hope such a view is shared by Tucker and Folkar and endorsed by all those with responsibility for junior doctors.

• © 2010 Royal College of Physicians