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Patient safety and quality of care continue to improve in NHS North West following early implementation of the European Working Time Directive

(CC)
J. Collum , J. Harrop , M. Stokes , D. Kendall
DOI: http://dx.doi.org/10.1093/qjmed/hcq139 929-940 First published online: 25 August 2010

Abstract

Objectives: NHS North West aimed to fully implement the European Working Time Directive (EWTD) 1 year ahead of the August 2009 national deadline. Significant debate has taken place concerning the implications of the EWTD for patient safety. This study aims to directly address this issue by comparing parameters of patient safety in NHS North West to those nationally prior to EWTD implementation, and during ‘North West-only’ EWTD implementation.

Design: Hospital standardised mortality ratio (HSMR), average length of stay (ALOS) and standardised readmission rate (SRR) in acute trusts across all specialties were calculated retrospectively throughout NHS North West for the three financial years from 2006/2007 to 2008/2009. These figures were compared to national data for the same parameters.

Results: The analysis of HSMR, ALOS and SRR reveal no significant difference in trend across three financial years when NHS North West is compared to England. HSMR and SRR within NHS North West continued to improve at a similar rate to the England average after August 2008. The ALOS analysis shows that NHS North West performed better than the national average for the majority of the study period, with no significant change in this pattern in the period following August 2008. When the HSMRs for NHS North West and England are compared against a fixed benchmark year (2005), the data shows a continuing decrease. The NHS North West figures follow the national trend closely at all times.

Conclusions: The data presented in this study quantitatively demonstrates, for the first time, that implementation of the EWTD in NHS North West in August 2008 had no obvious adverse impact on key outcomes associated with patient safety and quality of care. Continued efforts will be required to address the challenge posed nationally by the restricted working hour’s schedule.

Introduction

Since August 2009, doctors in training in the UK have been required by law to work an average of no >48 h/week, calculated over a 26 week reference period. The legislation underpinning this originated from Europe in 1993 and was originally termed the European Working Time Directive (EWTD). This directive was incorporated into UK law in 1998 under the Working Time Regulations (WTR) and the restriction of doctors’ working hours was gradually implemented, allowing an incremental reduction to 48 h by August 2009.

There has been significant debate concerning the implications of the EWTD for patient safety and junior doctor training. Although the initial intention in applying this legislation was to improve patient and doctor safety through reduction in working hours, concerns regarding the threat to quality of training, service provision and continuity of care have been aired with regularity. Alongside this, the implicit concern that patient safety could be adversely affected has received widespread press coverage.1–4 However, there is no robust evidence to uphold the viewpoint that the adoption of a restricted working hours schedule will impair patient safety, directly or indirectly.

Conversely, there is a body of evidence to support the reduction in doctors working hours with reference to improving patient safety and reducing serious medical error. A number of studies conducted in the USA in recent years provide evidence for increased serious medical error in those working prolonged shifts compared with those undertaking restricted hours.5,6 Similarly, an incremental increase in adverse patient safety incidents with successive prolonged shifts, especially night-shifts, has been well demonstrated.7 The Royal College of Physicians Multidisciplinary Working Group published guidance in 2006 which recommended the cessation of traditional full-shift working practises involving blocks of seven 13-h night-shifts, and endorsed a limit of four successive night-shifts that should be minimized in length where possible.8 A prospective study, recently undertaken in the UK, has demonstrated a marked decrease in medical error rates amongst doctors working in an EWTD compliant rota when directly compared to a group undertaking a traditional 56 h/week working pattern.9 Moreover, the 2009 postgraduate medical education and training board (PMETB) national survey of trainees provides evidence that trainees operating within the 48-h limit are significantly less likely to report serious error.10

The EWTD was not the first move to restrict working hours for junior doctors; the New Deal junior doctor contract, agreed in 1991, stipulated maximum shift lengths, maximum weekly working hours (depending on shift type) and outlined minimum rest requirements.11 This contract embodied the viewpoint that junior doctors, alongside other workers, were entitled to adequate work/life balance and epitomized the wider perspective that ‘tired doctors are not safe doctors’.12

The actual implementation of an average 48-h working week represented a significant challenge to the organization and provision of clinical services across the country; in recognition of this, and in order to lead the way in EWTD implementation, NHS North West undertook a project which aimed to implement the EWTD 1 year ahead of the August 2009 deadline.13

Although there is now an accumulation of evidence to support the viewpoint that patient safety is improved by restricted working hours amongst doctors, there are no objective UK data examining quantitative parameters of patent safety in an environment where the EWTD limit has been implemented. The unique circumstances existing in the UK from August 2008 allow us to compare the performance of a largely EWTD compliant region (NHS North West) to the rest of England, which had not yet implemented the 48-h limit. These circumstances allow us to test the hypothesis that implementation of the EWTD in the North West has had no adverse impact on several key outcomes associated with patient safety.

This study aims to compare parameters of patient safety in NHS North West to those nationally, prior to EWTD implementation, and after ‘North West-only’ EWTD implementation. In devising this study, we considered hospital standardised mortality ratio (HSMR), average length of stay (ALOS) and standardised readmission rate (SRR) in acute trusts, across all specialties, to be suitable quantitative indicators of patient safety and quality of care.14–16

Methods

Data for this study were collected and analysed by Dr Foster Intelligence. The information is based on the data which is routinely collected from day case and inpatient records throughout the NHS. These data were then extracted for analysis by the Dr Foster Unit at Imperial College London through the secondary users service (SUS). The data were cleaned and anonymized according to established hospital episode statistics (HES) guidelines. HSMR, ALOS and SRR across NHS North West were analysed retrospectively for the three financial years 2006/2007 to 2008/2009 (effectively April 2006 to March 2009). These figures were compared with the national data for the same parameters. No individual patients were identifiable in this study.

The HSMR compares the number of expected deaths with the number of actual deaths in a ratio [(observed deaths/expected deaths) × 100.] The HSMR analysis was performed for acute trusts only, across all specialties. The expected counts are derived using logistic regression and are adjusted for factors to indirectly standardize for difference in case mix, including: (i) sex, (ii) age group (in 5 year bands up to ≥90), (iii) method of admission (non-elective or elective), (iv) the socio-economic deprivation quintile of the area of residence of the patient (based on the Carstairs Index),17 (v) primary diagnosis (based on the Clinical Classification System), (vi) co-morbidities (based on Charlson Score),18 (vii) number of previous admissions, (viii) month of admission (for certain conditions where seasonal variation may be important, e.g. respiratory infection) and (ix) whether a patient is being treated within the specialty of palliative care.

A published methodology for calculation of HSMRs was utilized; however, a detailed description of this methodology is beyond the scope of this article and can be found in our references.19

ALOS analysis measures the average duration of all patient episodes in hospital across acute trusts, across specialties, from the day of admission to the day of discharge, divided into elective and non-elective groups.

The SRR analysis takes into account the number of emergency readmissions to acute trusts across specialties within 28 days of discharge, where readmission was not part of the planned treatment. The rate is calculated by dividing the observed readmissions by the expected readmissions. Both are indirectly standardized for the following factors: (i) age on admission (in 5 year bands up to ≥90) (ii) sex, (iii) admission method (non-elective or elective), (iv) socio-economic deprivation quintile of the area of residence of the patient (based on the Carstairs Index), (v) primary diagnosis (based on the Clinical Classification System), (vi) co-morbidities (based on Charlson Score) and (vii) year of discharge (financial year).

Results

The HSMRs by month for NHS North West and England are included in table form with associated confidence intervals (Tables 1 and 2). When the HSMR analysis for NHS North West is plotted alongside the national trend, a similar pattern for both can be seen throughout the period of analysis.The green markers in Figure 1 show where the HSMR is statistically low in a given month and red markers show where the HSMR is statistically high. When the HSMRs for NHS North West and England are compared against a fixed benchmark year (2005) the data shows a continuing decrease (Figure 2). The NHS North West figures follow the national trend closely at all times.

Figure 1.

North West SHA HSMR by month from April 2006 to March 2009.

Figure 2.

North West SHA & England HSMR by month from April 2006 to March 2009 with 2005 benchmarks.

View this table:
Table 1

National HSMR by month

Financial yearFinancial monthObservedExpectedRelative riskLow-confidence limitHigh-confidence limit
2006114 03313 481.11104.09102.38105.83
2006216 22115 947.86101.71100.15103.29
2006315 77616 110.8497.9296.4099.46
2006416 10615 296.74105.29103.67106.93
2006515 28915 344.2799.6498.07101.23
2006614 66215 208.4996.4194.8597.98
2006715 76316 023.8898.3796.8499.92
2006816 08816 790.1695.8294.3497.31
2006917 31618 300.0694.6293.2296.04
20061019 04219 619.1397.0695.6898.45
20061117 90917 622.42101.63100.14103.13
20061217 68118 007.1498.1996.7599.65
2007116 27115 629.61104.10102.51105.72
2007215 90715 988.0399.4997.95101.05
2007314 83715 172.6897.7996.2299.37
2007414 74914 863.6099.2397.63100.84
2007514 74515 129.3597.4695.8999.05
2007614 29914 104.40101.3899.72103.06
2007715 51115 980.7497.0695.5498.60
2007815 80616 462.0096.0294.5297.52
2007917 99818 069.5599.6098.15101.07
20071019 23919 501.5898.6597.26100.06
20071116 15016 694.9696.7495.2598.24
20071216 87816 563.64101.90100.37103.45
2008116 75416 220.77103.29101.73104.86
2008215 74915 588.59101.0399.46102.62
2008314 58514 562.62100.1598.53101.79
2008414 69015 177.7596.7995.2398.36
2008514 00114 212.5098.5196.89100.16
2008614 19514 619.8997.0995.5098.70
2008715 72816 236.2396.8795.3698.40
2008816 36316 082.91101.74100.19103.31
2008921 39720 933.96102.21100.85103.59
20081021 36220 843.53102.49101.12103.87
20081115 93716 655.3895.6994.2197.18
20081216 27017 480.9793.0791.6594.51
View this table:
Table 2

North West SHA HSMR by month

Financial yearFinancial monthObservedExpectedRelative riskLow-confidence limitHigh-confidence limit
2006121742013.41107.98103.48112.61
2006225242426.19104.03100.01108.17
2006324202437.9399.2695.35103.30
2006424472312.69105.81101.66110.08
2006523852371.77100.5696.56104.68
2006624172366.47102.1498.10106.29
2006724622432.38101.2297.26105.30
2006825512517.56101.3397.43105.34
2006926872748.3097.7794.11101.54
20061030113022.3399.6396.10103.25
20061129322732.56107.30103.45111.25
20061228682731.41105.00101.19108.92
2007125662382.54107.70103.57111.95
2007224472435.41100.4896.53104.54
2007324182351.75102.8298.76107.00
2007423572329.77101.1797.13105.34
2007523912322.09102.9798.88107.18
2007623232172.73106.92102.61111.35
2007724592469.3999.5895.68103.59
2007824782474.66100.1496.23104.16
2007928162753.61102.2798.52106.11
20071029522878.55102.5598.89106.32
20071126182600.77100.6696.84104.59
20071227632535.65108.97104.94113.11
2008126162451.13106.73102.68110.90
2008224642382.25103.4399.39107.60
2008322252206.16100.8596.71105.13
2008423732345.23101.1897.15105.34
2008522242181.87101.9397.74106.26
2008621932233.2098.2094.13102.40
2008723752451.0696.9093.04100.87
2008826112520.76103.5899.64107.63
2008934203253.10105.13101.64108.71
20081032573090.39105.39101.80109.07
20081124812560.7596.8993.11100.77
20081224892618.4895.0691.3698.86

The ALOS by month for NHS North West and England are included in table form with associated confidence intervals (Tables 3 and 4). When the ALOS for elective and non-elective patients across NHS North West is plotted alongside the national trend, once again a similar pattern for both can be seen throughout the period of analysis (Figures 3 and 4).

Figure 3.

North West SHA & England Non-Elective ALOS by month from April 2006 to March 2009.

Figure 4.

North West SHA & England Elective ALOS by month from April 2006 to March 2009.

View this table:
Table 3

National ALOS by month

Financial yearFinancial monthNon-elective spellsNon-elective bed daysNon-elective Length of stayElective spellsElective bed daysElective length of stay
20061560 1553 583 9236.39140 734866 8336.16
20062592 0283 994 0766.74156 534986 6316.30
20063581 9553 786 2756.50160 436952 4935.94
20064584 2653 695 3846.32158 0241 035 4066.55
20065577 9353 641 0416.29154 641882 0575.70
20066579 3373 731 8106.44156 131995 2536.38
20067586 8013 646 8846.21159 991983 9716.15
20068575 0323 567 7356.20164 885913 6535.54
20069581 5383 742 3296.43146 7652 366 56316.13
200610592 8613 734 3956.29151 422879 1715.81
200611540 8713 433 5786.34150 222867 5185.78
200612587 6853 712 3076.31174 312931 6915.35
20071553 9473 344 4406.04138 287879 9246.36
20072585 3763 476 3645.94155 913891 6885.72
20073568 2083 397 5845.98155 662890 0685.72
20074580 8923 410 5035.87156 801895 3935.71
20075575 5853 335 3385.79151 315876 2605.79
20076552 8123 076 0035.56149 001873 9065.87
20077589 0253 427 2315.82162 997880 1085.40
20078571 2853 341 1695.85163 992894 8505.46
20079571 0933 211 6115.62136 217812 5655.97
200710582 0383 581 7226.15151 025807 9395.35
200711552 3513 329 5216.03162 077850 2975.25
200712581 3933 333 7785.73149 936913 1876.09
20081584 1233 708 2916.35156 591984 9436.30
20082598 4583 393 1585.67152 879887 1175.80
20083577 8533 366 7175.83150 938903 2245.99
20084605 8293 547 5415.85162 843924 7915.68
20085578 4183 181 3515.50143 983824 6245.73
20086587 0793 449 6865.88153 500894 0245.82
20087613 6803 546 1115.78166 553955 7575.74
20088584 6863 337 4975.71154 400873 6695.66
20089621 5473 716 8615.98137 479899 8856.55
200810595 5323 645 5586.12140 080804 1235.72
200811554 1043 323 3366.00141 818815 7105.75
200812631 3383 648 7235.78160 270919 4995.73
View this table:
Table 4

North West SHA ALOS by month

Financial yearFinancial monthNon-elective spellsNon-elective bed daysNon-elective length of stayElective spellsElective bed daysElective length of stay
2006187 774567 6226.4720 685109 6695.30
2006292 023585 1586.3623 376112 8054.83
2006389 767567 2186.3224 043136 0445.66
2006490 521537 8835.9423 041126 5815.49
2006589 401544 9066.1022 599116 4315.15
2006689 872541 3696.0223 068151 7776.58
2006791 568535 5395.8524 012121 5175.06
2006890 001556 1216.1825 029120 2214.80
2006991 089514 3355.6521 339118 4535.55
20061093 352565 5956.0622 850101 8814.46
20061183 742527 2366.3022 388113 1425.05
20061290 558561 9646.2125 936130 4495.03
2007188 458517 7855.8521 545116 5155.41
2007293 483540 7775.7824 072118 3754.92
2007390 220523 0845.8024 237114 8784.74
2007493 827523 9285.5824 202120 8774.99
2007592 812504 3555.4323 455104 5164.46
2007689 982470 7815.2322 848105 3494.61
2007795 081529 8605.5724 741116 2654.70
2007891 414513 8175.6225 191119 8044.76
2007992 676500 9425.4120 771122 1605.88
20071093 002552 9665.9523 19198 2634.24
20071189 292514 8655.7724 857114 6744.61
20071293 867512 5565.4622 277103 8584.66
2008192 079546 4105.9323 245117 3875.05
2008294 081523 6475.5722 803110 4064.84
2008390 082501 1805.5622 522105 4304.68
2008494 073520 4345.5324 350102 2104.20
2008590 485489 8875.4121 24691 7684.32
2008692 267506 9685.5022 395102 5854.58
2008797 068532 8575.4924 364113 1504.64
2008893 119514 1455.5222 29597 0444.35
2008997 674571 8885.8619 441103 4415.32
20081091 928547 4805.9620 60690 6104.27
20081187 712490 8655.6021 05392 1764.38
20081299 055565 9545.7123 726104 9214.43

The SRR by month for NHS North West and England are included in table form with associated confidence intervals (Tables 5 and 6). When the SRR for NHS North West is plotted alongside the national trend, once more a similar pattern for both can be seen throughout the period of analysis (Figure 5).

Figure 5.

North West SHA & England SRR by month from April 2006 to March 2009.

View this table:
Table 5

National SRR by month

Financial yearFinancial monthObservedExpectedRelative riskLow-confidence limitHigh-confidence limit
2006161 77850 436.30122.49121.52123.46
2006269 23957 676.69120.05119.15120.94
2006369 51257 772.29120.32119.43121.22
2006468 29257 034.15119.74118.84120.64
2006569 39057 492.49120.69119.80121.60
2006669 25857 925.42119.56118.68120.46
2006770 85159 064.74119.95119.07120.84
2006870 93059 066.35120.09119.20120.97
2006970 35459 568.54118.11117.23118.98
20061071 60259 798.56119.74118.86120.62
20061166 48254 341.69122.34121.41123.27
20061271 07554 246.35131.02130.06131.99
2007166 25951 504.84128.65127.67129.63
2007271 33755 979.51127.43126.50128.37
2007369 01654 409.31126.85125.90127.80
2007469 22054 669.00126.62125.68127.56
2007569 66554 620.95127.54126.60128.49
2007666 47752 145.72127.48126.52128.46
2007771 84756 217.44127.80126.87128.74
2007870 19655 260.18127.03126.09127.97
2007967 94654 289.95125.15124.21126.10
20071068 55554 791.32125.12124.19126.06
20071165 05152 294.03124.39123.44125.35
20071236 59249 068.0874.5773.8175.34
2008171 84157 512.20124.91124.00125.83
2008273 25459 478.17123.16122.27124.06
2008371 05457 757.49123.02122.12123.93
2008475 17160 505.15124.24123.35125.13
2008570 55257 349.53123.02122.11123.93
2008673 81059 520.53124.01123.11124.91
2008778 44363 154.74124.21123.34125.08
2008873 66359 833.17123.11122.23124.01
2008977 12563 916.94120.66119.81121.52
20081074 66360 653.37123.10122.22123.98
20081171 69156 232.84127.49126.56128.43
20081282 03258 641.91139.89138.93140.85
View this table:
Table 6

North West SHA SRR by month

Financial yearFinancial monthObservedExpectedRelative riskLow-confidence limitHigh-confidence limit
2006110 0398306.73120.85118.50123.24
2006211 1969525.46117.54115.37119.74
2006311 4319523.16120.03117.84122.25
2006411 1579444.98118.13115.94120.34
2006511 5469571.94120.62118.43122.84
2006611 7319690.57121.06118.87123.27
2006711 8759963.93119.18117.05121.34
2006811 9219963.52119.65117.51121.81
2006912 11110076.81120.19118.06122.35
20061012 24510141.02120.75118.62122.91
20061111 2829167.29123.07120.81125.36
20061211 9309090.89131.23128.89133.61
2007111 4738833.96129.87127.51132.27
2007212 2709577.94128.11125.85130.39
2007311 8909267.42128.30126.00130.63
2007412 2639370.85130.86128.56133.20
2007512 3219375.06131.42129.11133.76
2007611 8378980.58131.81129.44134.20
2007712 4749643.56129.35127.09131.64
2007812 1529425.46128.93126.65131.24
2007911 6879417.38124.10121.86126.37
20071011 9429308.81128.29126.00130.61
20071111 4259049.09126.26123.95128.59
20071264658458.4576.4374.5878.32
2008112 1939690.92125.82123.60128.07
2008212 4309985.39124.48122.30126.69
2008311 8789654.51123.03120.83125.26
2008412 4379964.42124.81122.63127.03
2008511 7559579.12122.71120.51124.95
2008612 4119928.49125.00122.81127.22
2008713 32110 550.22126.26124.13128.43
2008812 43910 105.70123.09120.94125.27
2008912 75510 547.43120.93118.84123.05
20081012 3179927.88124.06121.88126.28
20081112 1129426.93128.48126.20130.79
20081213 6549712.30140.58138.24142.96

Discussion

For the first time, we present quantitative data which demonstrates that implementation of the EWTD in NHS North West in August 2008 had no adverse impact on key outcomes associated with patient safety and quality of care. HSMR and SRR within the North West continued to improve at a similar rate to the England average after August 2008. The ALOS analysis shows that NHS North West performed better than the national average for the majority of the study period, with no significant change in this pattern in the period following August 2008.

When considering the HSMR trends in detail, three seasonal spikes in the death rate during the December to January period in each financial year analysed can be clearly seen; these occur nationally, and the pattern in NHS North West is no different from the national trend. When the NHS North West HSMR across acute trusts amongst elective and non-elective patients was analysed against 2005 benchmarks across the 3-year period, an overall improvement could be seen which matched the rate of overall HSMR improvement for England, and where the North West showed signs of a decline in improvement this is reflected in the national picture. There was no significant variation from the national HSMR trend immediately following EWTD implementation in the North West, or during the whole period of EWTD implementation from August 2008 until March 2009. Moreover, where NHS North West showed signs of a decline in improvement in the HSMR trend, this is reflected in the national picture demonstrating that this decline in improvement cannot be attributed to a localized issue.

The increase in HSMR in the North West in the winter of 2008/2009 should be examined. There is clear evidence to demonstrate that this increase in HSMR was reflected in the national trend, and this can be attributed to the severe winter pressures related to seasonal infection, exacerbation of chronic disease and hospitalization amongst the growing elderly population.20

Although HSMR figures are clearly a headline statistic when considering the impact of EWTD implementation in NHS North West, data concerning ALOS may provide valuable insights when considering the effectiveness of hospital institutions and clinical teams in satisfactorily and efficiently processing patients. Our data reveal a lower ALOS for both elective and non-elective patients at NHS North West in comparison to England throughout the period studied. Where there is a significant increase in the ALOS for England, this is mirrored at NHS North West. There is an uncharacteristic spike in the elective ALOS at the national level in December 2006 but there is also an increase, although much less significant, at NHS North West in the same month. In the period following August 2008, the ALOS for NHS North West continues to follow the national trend, although it remains lower than the national average. Therefore, it is clear that ALOS has not been impacted in any way that can be attributed to EWTD implementation.

Another useful marker to consider alongside the ALOS when assessing the effective provision of care is the SRR. SRR can provide telling data regarding the effectiveness of initial treatments and highlight those instances in which readmission has been required. When the emergency SRR at NHS North West is compared to that of England for the period April 2006 to March 2009, it can be seen that NHS North West plots a similar pattern to that of the national average. A significant divergence occurs in summer 2007, at which time the SRR in NHS North West rises above the national average. The reason for this is unclear. Similarly, there is a drop in SRR in March 2008 across both England and NHS North West. Again the reason for this is unclear and may be due to a data anomaly, but further investigation of this is beyond the scope of our report. However, it can be stated that the introduction of a 48-h week in NHS North West in August 2008 did not lead to any appreciable trend change in SRR or any significant divergence from the national average.

Much of the credibility of this study rests on the robustness of the HSMR as a measure of patient safety. Since the technique was devised by Jarman et al.21 in the UK in the 1990s, HSMRs have been utilized worldwide to focus the discussion of patient safety and quality improvement, to monitor the provision of care over time and to identify opportunities for improvement. It has become an internationally recognized objective measure of quality of care and, in the author’s opinion it is simply the best tool we currently have with which to quantify and monitor the difficult and multifactorial variables that comprise patent safety and quality of care.14 Indeed, the Canadian Institute for Health Information adopted HSMR analysis as recently as 2005 in order to drive their patent safety and improvement agenda.22 Certainly, the HSMR has its detractors and indeed many researchers do not consider the HSMR to be a suitable measure of, or surrogate marker for, patient safety.23 The pitfalls of HSMR analysis include the possibility for administrative errors such as miscoding and the possibility of missing data. However, missing data or miscoding would be unlikely to account for the clear and consistent trends that we have demonstrated.

The reliability of this article’s claim also depends on the EWTD compliance rate in the North West during the period August 2008 onwards. Robust data exist to demonstrate 94% compliance with a 48-h working week for junior doctors in the North West region of England in August 2008 and this has been published previously.13 Based on a published methodology, EWTD compliance was calculated using New Deal monitoring data.24 In addition, NHS North West did not take the approach of increasing junior doctor numbers and rather directed resources towards sustainable solutions. This did not include any significant targeted increase in the number of junior doctors, rather resources were directed towards ‘Hospital at Night’ schemes, extended practitioner roles and service reconfiguration; this approach was detailed in the article ‘Achieving the 48 h week for Junior Doctors in the North West’.13

Compliance across England did increase in the period leading up to 1 August 2009, as other trusts across England prepared for the EWTD deadline. Individual Strategic Health Authorities (SHAs), as part of their own quality assurance process, began the collection of compliance data in January 2009.25 This information was shared with the Department of Health, the Academy of Medical Royal Colleges and the medical professions. NHS North West’s own data for January 2009 showed that the North West was advancing at a greater pace than the rest of England. The stated EWTD compliance for England in January 2009 was 72%; this increased to 91% by August 2009. It is therefore clear that, during the period of interest (August 2008–August 2009), the North West had a significantly greater degree of compliance with EWTD than the rest of the country, making our comparison truly valid.

Finally, we recognize that the outcome measures in this article (HSMR, SRR and ALOS) are influenced by a multitude of factors other than the working arrangements of junior doctors and we cannot attribute any changes in these parameters to EWTD alone. However, our findings do support the hypothesis that implementation of the EWTD in the North West has had no adverse impact on several key outcomes associated with patient safety.

Conclusions

The implications of these findings are widespread; we can state for the first time that EWTD implementation in the North West region of England has had no obvious adverse effect on parameters of patient safety when considering HSMR, SRR and ALOS across acute trusts among elective and non-elective patients. In fact, there has been continued improvement in these parameters from August 2008, and where trends are at odds with expected results, this is mirrored nationally. No localized variance from national trends could be identified at any stage. The authors do not claim that patient safety improved because of the North West’s efforts to fully implement EWTD in August 2008, but simply wish to demonstrate that these activities did not result in any measurable negative impact on our stated outcome measures.

Patient safety is at the heart of the EWTD, and these results provide a firm basis to support a model which sees well-rested, well-supported doctors deployed efficiently and intelligently within a 48-h week. However, continued efforts will be required to address the challenge posed nationally by the restricted working hours schedule; we must endeavour to sustain excellence in postgraduate medical training and prioritize the continual improvement in quality of patient care within the limits of the WTR’s 48-h week.

Funding

NHS North West Strategic Health Authority.

Conflict of interest: None declared.

Acknowledgements

J.C. and D.K. developed the original idea for the study. J.C. wrote the first draft of the article and wrote subsequent drafts after feedback from the other three authors. All four authors gave final approval. We thank Dr Foster Intelligence for processing the data. We also thank Paul Barbour and James Thompson for their comments on earlier drafts of this manuscript.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.5), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

References

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