The European Working Time Directive (EWTD) was designed to enhance the wellbeing of European workers to ensure that they are protected from being obliged by employers to carry out excessive hours, healthcare workers included. However, it has had a profound effect on the structures of the working life of healthcare employees, with a knock-on impact on service delivery for patients. Primarily, compliance with the Directive will necessitate shift working patterns, rather than the present on-call structure. This has generated concern that it may result in deterioration of service delivery and in the quality of training, and in an inconsistent chain of patient care with cases being handed over more frequently and more medical errors as a result. Specialists fear that with a shift-work rota system in place in the radiology department, the resultant inadequate staffing levels may increase waiting lists and cause a backlog of patients.
How Could This Harm Patient Care?
There is concern that EWTD implementation may:
• Unbalance the continuity of care of patients and individual responsibility of doctors for their patients;
• Reduce outpatient clinic staffing levels, with increased waiting times;
• Exacerbate overcrowding in emergency services;
• Increase waiting times for diagnostic procedures, at the top of which, medical imaging;
• Increase the strain on primary care;
•Worsen the perceived quality of care amongst the general public should increased delays occur;
•Make present on-call working rotas impossible to work to, especially for smaller hospitals, which cannot keep up with service provision under a 48 hour limit;
• Increase the deficit in manpower;
• Reduce the quality of training, including a loss of contact time with trainers and loss of training experience during daytime hours, and
• Inhibit service provision. Radiologists who work on-call are not allowed to work the following day after performing their on-call duty. This may lead to shortages of available radiologists to handle daytime cases. This may generate a backlog and greater waiting times for imaging exams or even radiotherapy and other critical procedures.
Will the EWTD Adversely Impact Patients?
Across Europe, radiologists and medical professionals across the spectrum have voiced their concern that the Directive is detrimental to patient access and standards of care. A commentary from the Royal College of Physicians of Ireland (RCPI) says the following: “Implementation of EWTD as currently envisaged does not benefit patients, but serves to undermine medical care standards and to compromise quality of professional education and training of specialists. EWTD poses a very significant threat to continued provision of quality healthcare”.
What is the European Working Time Directive?
The European Working Time Directive is a directive from the Council of Europe (93/104/EC) that lays down minimum requirements in relation to working hours, rest periods, annual leave and working arrangements for night workers. Under the directive, each Member State must ensure that every worker is entitled to:
•A limit to weekly working time, which must not exceed 48 hours on average, including any overtime;
•A minimum daily rest period, of 11 consecutive hours in every 24;
•A rest break during working time, if the worker is on duty for longer than six hours;
•A minimum weekly rest period of 24 uninterrupted hours for each seven-day period, which is added to the 11 hours' daily rest;
•Paid annual leave, of at least four weeks per year, and
•Extra protection for night workers (e.g., average working hours must not exceed 8 hours per 24-hour period; night workers must not perform heavy or dangerous work for longer than 8 hours in any 24-hour period; there should be a right to free health assessments and in certain situations, to transfer to day work).
Patients may be shunted from doctor to doctor in a new shift-oriented system. The danger is that high frequency handovers and harried doctors on exhausting shift patterns may present real risks to patient safety — far more than the total number of hours worked. In the U.S. they have debated the same issue, with a consensus on 80 hours per week. In the case of Europe, it is thought that for certain specialists, a 60 - 65 hour working week, including time spent on-call, is more workable with fewer handovers and greater safety for patients.
The Faculty of Radiologists in Ireland specifically points to radiology as a vulnerable sector: “Demand for on-call radiology services has grown massively in recent years. In most departments, at least 10 - 15% of radiology activity is now provided out of normal working hours.” Obviously, the change to a new shift-based system will likely be a blow to these services.
The argument is that working excessively, the fundamental reason for the EWTD, is bad for doctors’ health, whether it will demand Herculean efforts to enact required changes in the current service delivery structures or not. The Directive has had a major impact on hospitals, where junior doctors traditionally endured 80- to 100-hour working weeks and medical errors were frequently attributed to staff exhaustion. Workers perform better when not exhausted – doctors are no different in this case.
The Directive also protects junior doctors from being pressurised by senior executives into performing unrealistic hours, and those overlong hours may not deliver better training or experience. Instead of interpreting the Directive to mean that greater numbers of doctors must be employed to cover shift-rota gaps, it may be better to delegate non-critical tasks to lower grade employees, with some additional training. Additionally, proper supervision of handovers is a must, whether they take place every eight or every 13 hours. Moreover, it should be noted that the 48- hour week is averaged out over six months – thus, there is some flexibility in service provision. Finally, these health and safety rules are for all workers – doctors included. The changeover, which has been taking place in gradual stages across Europe since the Directive became a legal obligation, must be closely managed to ensure that patients do not lose out in the new system.