Problem: Compliance with UK regulations on junior doctors' working hours cannot be achieved by manipulating rotas that maintain existing tiers of cover and work practices. More radical solutions are needed.
Design: Audit of change.
Setting: Paediatric night rota in large children's hospital.
Key measures for improvement: Compliance with regulations on working hours assessed by diary cards; workload assessed by staff attendance on wards; patient safety assessed through critical incident reports.
Strategies for change: Development of new staff roles, followed by change from a partial shift rota comprising 11 doctors and one senior nurse, to a full shift night team comprising three middle grade doctors and two senior nurses.
Effects of change: Compliance with regulations on working hours increased from 33% to 77%. Workload changed little and was well within the capacity of the new night team. The effect on patient care and on medical staff requires further evaluation.
Lessons learnt: Reduction of junior doctors' working hours requires changes to roles, processes, and practices throughout the organisation.