The European working time directive (EWTD) was introduced into National Health Service hospitals for doctors in training in August 2004.¹ Mounting evidence had shown that fatigue in doctors contributes to adverse events in patients.² However, the implementation of potential quality improvements requires an understanding of whole healthcare systems.³ Before the introduction of the EWTD, our stroke ward had a resident senior house officer who provided weekday care, ensuring that all patients were medically reviewed on a daily basis. This is required, …