The EWTD: An idea whose time has gone?

Opinion logoWith the Brexiteers having won the race to the bottom of the credibility pole, could this cloud of confusion have a silver lining? If there was one thing that broke the back of a failing Emergency Service, it was the European Working Time Directive (EWTD).

In 1998 the EWTD was enacted into UK law. It was the culmination of years of EU discussion in which our college and university leaders failed to highlight its disadvantages when applied to hospital medicine. Since then volumes of hot air have been wafted about and tomes of medical literature have been published on the subject, but nothing has been done to alleviate the situation.

Rarely is a single mistake or act of stupidity responsible for a crisis. Prior to the introduction of the EWTD, the hospital service in the UK had endured a savage reduction in bed numbers, thanks to the management creed that 100% bed occupancy was more efficient and would save money. What that actually did was to increase the risk of inappropriate patient management through the non-admission or the premature discharge of patients from hospital. When the number of medical emergencies increased, as a result of more patients with multiple medical problems, there was no slack left in the system to cope with this predictable tsunami.

Let’s step back to a time when we worked in medical teams led by one or more consultants. (Sadly none of our current Junior Doctors and less than half of our current Consultants will have been trained in that environment.)

By the 1990s my junior team comprised 1 PRHO, 1 SHO and 1 Registrar and we were part of a 1:5 Medical On-Call rota. Weekends were split which meant working Saturday or Sunday. Hence 3:5 weekends were free. During the day and night it was possible to allow junior members time off. It was up to me and my Registrar. There were few complaints and working on my team was popular. We achieved an average length of stay of 4 days. After each take day the team had 4 days to “recover”, amass experiences and do some specialist work, before setting forth on another voyage into the exciting unknown of Emergency Medicine.

Too few beds meant that bed managers liberally distributed my patients throughout the hospital. A pernicious game of “pass the patient” evolved if the patient wasn’t in “your ward”. Safari ward rounds were tiresome and patients were easily missed but we still maintained continuity of care.

In my hospital the first casualty of the EWTD was the loss of the On Call Rooms. They were refurbished as extra ITU beds. The junior doctors’ rota was decided by HR Department managers who were fearful of fines if rules were breached. Ward rounds became fragmented when “my” juniors were either doing a shift or had a period of compulsory time off. I might just as well have been a “one man team”!

Today a 9 hour shift is a mindless sequence of clerking patients in the knowledge that when the 9 hours are up one can drop everything. This does not encourage effort or commitment. It instils boredom and triggers clock-watching: tiredness comes from boredom and that is when mistakes are made.

The EWTD did not speed up patient throughput; it just added a level of bureaucracy to the inpatient journey.

Did the EWTD really make a difference to patient safety? Nobody has furnished any proof of that! What happened to that “buzz” amongst the juniors which used to characterise our On-Call days? Continuity of care, which is an integral part of gaining medical experience, became an exception rather than the rule. Agency replacements were made at short notice.

Could we repeal the EWTD for hospital medics?

Yes, but the shortage of medical beds would have to be addressed.

Dr Mark Aitken

[The views expressed in this post do not necessarily reflect those of Doctors for the NHS.]

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