Significant improvements in patient care usually require major organisational change. In reality, this inevitably means disruption and upheaval of working practices that have evolved over decades. The prospect of change creates uncertainty and an inertia that gets in the way of progress and improvement. Arguments for the status quo can often supersede the argument for change.

In the UK—and presumably throughout Europe too—hospitals are being thoroughly exercised by the urgent need to implement the European Working Time Directive (EWTD).¹ This states that the working week must be limited to 48 hours. Because doctors have traditionally worked excessively long hours, the EWTD is being applied to them in stages. But, by 1 August 2004, doctors may only work 58 hours per week. The EWTD is set within the framework of Health and Safety at Work legislation. This makes sense. Long hours of work contribute to high stress levels within the profession² and overwork is a factor in adverse clinical incidents.³ And it must be healthier to work for 58 than for 100 hours per week.

The organisational changes needed to create systems in which doctors’ working hours are within the limits set by the EWTD are enormous. Even some of the least radical changes that have been proposed—such as the move from on call rotas to shift work—have caused anxiety that the alterations to working practice will create “risks to patient care”. Specifically, there are worries that shift working will cause a “loss of continuity of care” and reduction in time available for training. The inevitability of the introduction of the EWTD—which, unlike other directives on doctors’ working hours, is in a legislative framework—has concentrated minds on solutions to these concerns. So, well directed, formal handovers have been championed as the “organisational antidote” that will preserve or even strengthen continuity of care. The huge clinical and educational benefits of working within functional teams are now being understood. Shorter hours with new styles of work are recognised as compensating for the loss of the apprenticeship approach to experiential learning that was the norm. More of the training curricula will have to be taught, not simply experienced, and the competencies claimed will be assessed to a common standard.

Nevertheless, there remain many anxieties about these changes and the impact on the quality of patient care. But trying to “solve” the problem of doctors’ hours in isolation from the whole healthcare system is a mistake. If the ultimate goal is to create systems in which patient care can be delivered well and safely, then care needs to been seen as a whole rather than in its constituent parts. Moreover, as health care changes, we need to develop systems that are appropriate for today’s health care and will benefit patient care. An example of the sort of change that has an impact on patient care is described in two papers in this issue of QSHC.^4,5 Medical emergency teams (METs) are multiprofessional teams that can be activated by any member of the hospital staff who sees grave clinical deterioration. The impact on patient care was clear: as MET calls increased, cardiac arrests fell from 6.5 to 5.4 per 1000 admissions. The introduction of these teams is something that all acute hospitals need to consider, and the basis for doing so is clearly of benefit to patient care. Despite the potential advantages to patients, the implementation of this organisational change to traditional working patterns was not straightforward. Ensuring appropriate utilisation was difficult because of “cultural” barriers. It seems that those traditional hierarchical behaviours that dictate how doctors and nurses react and work got in the way of people calling these life saving teams.

It is just this sort of organisational change which has a clear emphasis on what works for patients that should be considered within the context of EWTD. In the UK some hospitals are taking an organisational approach to the challenge of EWTD by working out what work done at night is essential and then putting into place multiprofessional night teams staffed with people who have the range of relevant competencies.⁶ Implicit in these “hospital at night” projects is the assumption that the work that should be done in the day must be done in the day, and that we need to move away from traditional ways of organising work. Teams need to be established that are linked to patient care. All characteristics of good team functioning—including leadership, communication, and shared goals—need to be understood and put into practice.

Traditional hierarchical consultant led teams rely on fixed points of contact such as the consultant ward and informal reporting “up the line”. Teamwork in this long established medical sense is perhaps better described as “didactic leadership”. This worked very well in the past but is now less effective and too cumbersome, fragmented, and insecure to maintain good care and clear communication, especially when several doctors of the same grade are responsible to one consultant. Moreover, the combination of the drive to reduce hours and increasing sub-specialisation has increased the number of doctors seen by an individual patient in one admission. Too many people in the decision making hierarchy can cause potentially harmful diagnostic or therapeutic delays. In complex clinical situations, standardised shared protocols are safer than multiple individual approaches to decision making. Despite these arguments, it will be difficult to move away from well established working practices, even if they are well past their “use by date”.

Meeting the requirements of the EWTD is daunting, but there is an accruing amount of experience that can be used to inform the necessary changes. The MET study is one of these. It demonstrates one approach to organising patient care that may be of direct relevance. It also shows that implementation will be tough; old habits die hard. But a crucial lesson which we should all take from this study is the importance of evaluating the impact of any such change in terms of its effect on the quality and safety of patient care. The argument for new ways of working, such as the “hospital at night” project, will only be won when it can be shown that there are clear benefits to patients. EWTD legislation aims to improve the lives of doctors and other healthcare staff. It will only achieve this if we can also define processes that provide better care.