The role of the consultant paediatrician – case study
Dr Robert Scott-Jupp, consultant paediatrician, Salisbury Hospital NHS Foundation Trust
Salisbury District Hospital is a rural district general hospital, 25 miles from the next nearest paediatric unit. It serves a child population of 40,000, has a level two neonatal intensive care unit and delivers 2,500 babies per year.
When the hospital decided to maintain 24 hour cover, at a time when it had insufficient middle grade numbers, the trust agreed to increase consultant numbers to enable consultants to operate a resident on call rota.
Initially there were four consultants, which was then increased to six, with the new posts being filled by consultants who had already experienced resident on call duties elsewhere on a locum basis.
Although the on call rota started with five consultants the sixth who was nearing retirement opted out, now all six contribute to a 12 week rota in which out of hours are staffed on a 50:50 basis by consultants and middle grades, all working the same 13 hour shift pattern.
Consultants also act as second on call from home, supporting either another consultant or a middle grade.
Certain conditions were required by the consultants, a day off following resident on call and acceptable sleeping conditions in designated accommodation in the hospital and not being on call without a resident doctor.
Dr Robert Scott-Jupp, paediatric consultant and author of the Consultants Sleeping In article in BMJ Careers (9th April 2005, read here), says: "We felt it was important to agree these conditions at the start."
Initially the day off after on call involved the cancellation of some clinics, leading to daytime working being 'squeezed'.
Dr Scott-Jupp said: "The rota meant that day times were dedicated to clinics, emergencies and clinical work, with little time for the non clinical work including teaching, appraisals, audits.
"And there was added pressure on clinics from the 18-week waiting time targets."
Now, the trust has agreed to increase the number of consultants to 10 whole time equivalents (WTE) to address those problems and to enable European Working Time Directive (EWTD) 2009 compliance, involving consultants covering more day time emergency work and out of hours in place of registrars.
Dr Scott-Jupp says there are obvious benefits for patients and junior medical and nursing staff from the resident on call. Children coming to the hospital at night receive a consultant opinion and, where appropriate, can be referred to a later outpatient clinic, giving patient and consultant continuity of care.
Improved supervision of junior medical and nursing staff includes good teaching opportunities for trainee GP SHOs.
He believes that although there are personal benefits for the consultants (days off during the week including after a night on call), there should be an opt out on some grounds. These include age (consultants nearing retirement do not always want to be resident oncall), pregnancy, young family or health issues.
“Opt outs would make rotas more difficult so there would have to be a degree of compromise,” he says.
Dr Scott-Jupp believes that the system works best in units which are not excessively busy.
He advises consultants considering new working patterns to consider its benefits carefully and not be “horrified” at the prospect of resident on call.
