Northumbria Healthcare NHS Foundation Trust - the challenges of introducing HaN across a huge geographical region

Northumbria Healthcare NHS Foundation Trust is geographically one of the largest Trusts in the country, providing care to over half a million people in North Tyneside and Northumberland.

It comprises three district hospitals in urban centres and six community hospitals covering large rural areas.

The current ten year plan sets out to centralise emergency care in a new £75m specialist emergency care hospital near Cramlington, and to spend a further £125m upgrading North Tyneside and Wansbeck General Hospitals and rebuilding some community hospitals.

The Trust was also a foundation pilot for modernising medical careers (MMC) and is a participant in the new foundation programme starting in August 2010.

Northumbria first established Hospital at Night (HaN) to support the smallest district general hospital which was too small to sustain trainees and the larger hospitals followed its example.

Medical director David Evans believes Hospital at Night (HaN) has enabled Northumbria Trust to design patient services and working patterns to provide good quality, safe medical care overnight and support focused time for medical training.

The present system, introduced for the period until all emergency care is centralised, means that night nurse practitioners provide the key roles in HaN in all three district hospitals.

In the two larger hospitals, they are supported by acute care physicians on duty until late evening and on site resident medical officers. In the smallest Hexham Hospital, support comes from either an on site doctor in the emergency admissions unit or an on call consultant at home.

David believes that one key to HaN's success in Northumbria is that nurse practitioners were trained in house by a senior lecturer in medicine based in the Trust, he said: “Grow your own. Our practitioners were all senior nurses in the Trust and we taught them the clinical skills that were necessary in the context of our system and our expectations. Now they form an important resource.

"As a Trust we value the significant expanding role of nurses and other practitioners who already play a responsible role in our six community hospitals and in nurse led chemotherapy units and midwifery led units, all working to established protocols to ensure safety.

"As we make our changes to emergency care, we plan for our elective rehabilitation units also to be nurse-led."

David also emphasises the need for good communication and says staff must have the information they need to ensure that HaN succeeds. He said: "Those on duty overnight now have a broad view of what is happening in the hospital; if a consultant highlights at the handover a particular patient who may cause concern, they can be confident they will be looked after. It is a different way of ensuring the hospital is safe overnight."

David says there is now more of a coordinated approach to patient care ‘whereas in the past junior doctors may have felt inclined to sort it out alone'.He also says there is no evidence of a deterioration in care since the introduction of HaN and no adverse comments from patients who were seen by a nurse instead of a doctor.

In conjunction with HaN, the Trust invested in the roles of clinicians to provide an extended daytime service and made changes to on-call rotas and medical training. David said: "We were committed to providing three on-call rotas, one at each of our district hospitals, which was a big ask.

"The Trust changed junior doctor rotas from the traditional vertical streams; surgical, medical and orthopaedic to three four-month rotas. They covered 'front of house' including acute admissions and medical units, 'back of house' which was ward based and another choice of 'ology.'

He explains that because 70% of the Trust's patients are emergency admissions, many from an ageing population with a legacy of chronic respiratory disease, junior doctors' support is needed behind the A&E departments. David said: "That's the 'hot house' where they get fantastic exposure to patients, with consultants working extended hours to give them support."

Another four months is spent as part of a ward based cohort of junior doctors, working an extended schedule into the evening with night nurse practitioners.