Outcomes of the European Working Time Directive

The European Working Time Directive was produced by the Council of the European Union in 1993 and incorporated into British law in 1998 as the Working Time Regulations.1 Various aspects of the directive have had a major effect on the practice of medicine in the United Kingdom, most importantly the reduction in the maximum working week to 56 hours in 2007, a planned further reduction to 48 hours in 2009, and the need for a minimum of 11 hours’ rest in any 24 hour period.

Although not clearly stated in the directive, the aims of the council presumably were to protect workers from being coerced by employers to work excessive hours; to improve the quality of life of workers by permitting sufficient free time for family and leisure; and to reduce risk caused by tired workers. Although many industries are affected by the change in the law, medicine poses particular problems because of the need to train junior medical staff and to provide a 24 hour service that can respond to variable demand while ensuring continuity of, often complicated, patient care. Furthermore, unlike many other professions, junior and now senior doctors are paid per hour, which exposes the length of the working day and week to legislation.

If the directive was meant to improve clinical care and the quality of life and training for junior medical staff, its effect has been the opposite. The changes to working hours have had a major negative effect on the working life, free time, and education of junior doctors in the NHS.2 3 Although efforts have been made to create compliant rotas, continuity and quality of care have also been adversely affected in many services across the NHS.2 3 4The Royal College of Surgeons’ survey of junior doctors in 2005 showed that—since implementation of the directive—75% of juniors think that continuity of care has deteriorated, around 90% think that direct contact with patients and training have decreased, and more than half of specialist registrars think that their quality of life is worse on partial shifts.2 The reduction from 56 to 48 hours a week will lead to another 12% fall in daytime availability of junior doctors in the average rotation, further decreasing direct contact with patients, quality of care, and training of junior staff.5 This year the BMA Junior Doctors Committee accepted that a 48 hour week was not compatible with surgical training,6 and a recent BMA survey indicated that 57% of junior doctors and 67% of all grades think that doctors should be able to opt out of the 48 hour week.7

It is therefore time to ask whether the current law is succeeding in the above aims and whether these cannot be better achieved by a relaxation of the regulations. Historically, Britain—like many other countries—exploited junior doctors with work patterns that often required 80 or more hours on duty each week. These hours were remunerated poorly, with overtime initially not paid and subsequently paid at only 30% of the basic hourly wage. This practice had, however, largely disappeared by the 1990s, when changes in pay meant that employing doctors for long hours was more expensive than employing more doctors.

Numerous studies have shown that excessive hours of work and prolonged shifts increase the risk of work related errors, injuries while at work, and accidents after work.8 9 10 11 Most of these studies have looked at medical employees working more than 80 hours a week, with shifts of longer than 24 hours,10 11 although in other industries shifts of longer than 16 hours have been shown to increase risks.8 9 The reduction under the European Working Time Directive to a maximum 56 hours a week (and 48 hours planned in one year) has, however, dramatically changed working patterns. More than half of senior house officers in the 2005 UK Royal College of Surgeons survey were doing full shift rotas.2 This can be more tiring and disruptive to people’s social lives than a normal working week with one or two nights on call and no need to switch to a different sleep pattern. There is an argument that it is less tiring to work a 36 hour period with several hours of sleep than to work five consecutive nights on call with no sleep during the night while trying to sleep during the day.12 13 Complicated rotas, driven in part by the new deal covering on call and weekends, also reduce the number of free weekends because of the need to split the weekend. A court ruling by the European Court of Justice that every hour on call—even when at home undisturbed or asleep in the hospital—is an hour worked has added to the difficulty (SiMAP ruling 14).

The adjustment of working patterns in hospitals to accommodate the directive creates problems of combining continuity of patient care with appropriate training and a reasonable quality of life for staff. Junior doctors have to spend an increasing proportion of their working time “handing over” to incoming staff, therefore reducing time available to provide direct patient care. A high proportion of the working week is spent on solitary out of hours shifts with little or no training value; this will get worse with the introduction of a 48 hour week.2 3 5 Many specialties are sharing junior staff because of insufficient numbers of juniors to provide a “legal” rota. This almost invariably results in poorer continuity of care and inadequate communication between junior doctors and nursing staff and between junior doctors and on-call consultants. As a consequence, many patients—particularly in larger specialties such as general medicine and surgery—will receive almost no routine care at night and at weekends. These problems cannot simply be solved by employing more junior doctors because this reduces each doctor’s contact with patients and, therefore, training.

British medicine is highly respected worldwide because of the training provided and the breadth of experience and clinical expertise displayed by most consultants and general practitioners. This results from the length of training and the experience gained by doctors through direct contact with patients on the wards, clinics, and operating theatres. Reading and lectures are no substitute for this experience.

The European Working Time Directive is not achieving any of its presumed aims for junior medical staff—quality of life has not improved, training has deteriorated, and, for most patients, medical care is not safer.2 3 4 5 We therefore call on the British government, in collaboration with other European countries facing similar problems,3 6 15 16 to abandon the tightening of maximum working hours from 56 to 48 hours and to reduce the minimum daily rest from 11 to eight hours. Probably only Sweden, Denmark, and the UK will be able to comply with the 48 hour limit for junior doctors by August 2009,3 6 which suggests that such a move by the British government might be widely supported across the European Union. At the very least, hospitals and medical staff should be exempt from the 48 hour limit. The concept of “on call” not contributing in full to the total hours of work should be reintroduced—this seems to have been accepted, in principle, by a recent meeting of European Union employment ministers.6

Professionals often choose to work long hours because they enjoy their work, and from a desire to provide a good service and to improve their expertise in their chosen profession. Although limits need to be set on the number of hours people work, the change from 56 to 48 hours is a step too far. The creation of complicated rotas, full shifts, and cross cover is not the solution to a fundamentally flawed reduction in hours of work.