Introducing the new pilot sites

Skills for Health - Workforce Projects Team has worked with a range of pilots to look at different solutions to the WTD 2009 requirement. Current pilots have explored solutions in mental health, in small and isolated sites and looking at services over the full 24 hour period to name a few. A selection of new pilots aim to look at different scenarios offering learning to the wider NHS.

Looking at meeting WTD 2009 in paediatrics, in a rural setting or re-designing junior doctor rotas, these three new pilots will explore the different challenges that the health and social care communities will face in meeting compliance.

Royal Liverpool Children’s NHS Trust

Redesigning paediatric care delivery

Alder Hey Hospital was founded in 1914, and is one of the largest and busiest children’s hospitals in Europe. The Royal Liverpool Children’s NHS Trust is recognised as an international centre of excellence, with a proud history of medical achievement and clinical innovation.

More than 200,000 children a year are treated from all over the North West, North Wales, Shropshire and the Isle of Man. As well as being a tertiary referral hospital for many specialties, the trust also provides general paediatric service and clinics for the locality. The Royal Liverpool Children’s NHS Trust is a teaching hospital involved in the training of more than 600 under graduate medical students. With 2,500 staff, 309 beds and over 20 specialist services, it manages more than 800 clinics over 31 different sites across a population of 7.6 million people. This is in addition to managing community services on 38 sites across Liverpool. It is nationally acknowledged that paediatric services face particular problems in achieving WTD compliance because of their inability to participate in the cross-cover arrangements that underpin the Hospital at Night strategy.

The trust employs 118 junior doctors and to implement a 48 hour week would result in the loss of junior doctors to service of 752 hours per week. The size and the scale of the task indicates that no one solution will meet the individual requirements of various services across the trust. The trust conducted an audit of out of hours workload undertaken by junior doctors and senior nurses. The results of the audit identified a number of opportunities for reducing the workload of junior doctors by transferring tasks to clinical support nurses.

Compliance will be delivered through a programme approach of related projects, which together will influence and shape the learning of implementing new ways of working to meet working time directive as well as delivering an improved service to our children and young people.
The projects will reduce the workload intensity of junior
doctors by:

• Development of clinical skills of existing support nurses to provide increased levels of support through the implementation of a Paediatric Early Warning Tool
• Implementation of Patient Group Directives (PGDs) within the A&E setting for senior nurses to prescribe and dispense identified medication out of hours
• Implementation of nurse led discharge on the acute admissions ward.

The pilot is expected to be complete by September 2008.

3 x 9 hour shift pattern

University Hospitals Coventry & Warwickshire NHS Trust - Redesigning traditional junior doctor rotas.

In 2009, all NHS trusts will be required to reduce junior doctors’ work hours from a maximum of 56 to a maximum of 48 hours per week.

The UK Multidisciplinary Working Group proposed a theoretically optimised rota that is built around 9-hour shifts. This rota was derived from industrial models of shift-work and performance, adapted to meet the needs of junior doctors. Field data on the effect of this rota in medical settings has not been collected, and surveys of doctor opinion may not be objective. Skills for Health - Workforce Projects Team has commissioned this study, to compare the 48 hour 3 x 9 hour shift with the traditional 56 hour rota system. This pilot uses validated methods to assess the effect on doctors well-being, whilst ensuring patient safety, in a complex and demanding acute medical setting.

University Hospitals Coventry & Warwickshire (UHCW) NHS Trust in Coventry is piloting the study on its Acute Medical Rota. All doctors in this study are senior house officers (SHOs). This large progressive NHS trust has been chosen for the complexity of the rota systems which involves many different medical sub-specialities. The cell size of 9 doctors on the rota is achieved by combining an acute medicine cell of 5 doctors with the cell of 4 doctors in endocrinology. As smaller trusts may have difficulty constructing rota cells larger than 9, the findings of this study will be more generally applicable than the recommended cell size of 10 doctors. The study will compare the medical SHO rota at UHCW on two different rotas.

Rota A is an adaptation of the current rota, where junior doctors work 54 hour weeks with blocks of three and four 12.5 hour night shifts in succession. Rota B is the new schedule where 9 doctors work a rota that has been adapted to a 48 hour week with blocks of three nine-hour night shifts, and only occasionally work two nights in succession. This study looks at four parameters on which the rota change is expected to have beneficial impact

• Patient safety
• Doctors’ rest and sleep
• Doctors’ quality of life
• Quality of handover information.

The 3x9 hour shift using a cell size of 9 doctors aims to demonstrate that it is possible to reduce the workload of doctors in training and equivalent grades to be WTD 2009 compliant. The benefits of this study are predicted to be an improvement in patient safety and a reduction in doctors’ fatigue.

Milton Keynes General NHS Trust

WTD 2009 compliance through the improved management of emergency admissions and changed ways of working

Milton Keynes General is a medium sized general hospital providing services to the residents of Milton Keynes and surrounding rural areas.

It has a culture of delivery and innovation. The increase in population of Milton Keynes, currently estimated at 270,000, has placed high demands upon the local health service in both the acute and primary care sectors. This population is estimated to grow to 412,000 by 2031. As the main local provider of acute health services, Milton Keynes prides itself on delivering quality care to the local people. The hospital currently has under 500 inpatient beds and provides the comprehensive range of general acute and surgical, elective, paediatric and maternity services. Milton Keynes General plans to grow its services to meet the needs of the expanding population and to provide care closer to home. The challenges of WTD 2009 allow an opportunity for Milton Keynes General to review the delivery of services and the training of junior doctors.

Recognising a whole system approach, Milton Keynes General will work across organisational boundaries, for example with the local ambulance trust, PCT, social care and practice based commissioners, in the improved management of emergency admissions. Part of the focus on emergency care will be in preventing emergency admissions. For those patients that are transferred into the acute trust Milton Keynes General will provide fast access and high quality care with an appropriate skill mix of staff.

Milton Keynes General will complete a comprehensive analysis of work undertaken at night by all staff groups to identify the skills required to deliver care out of hours. The outcome of this work will inform the planning of the day and night team concept. The trust will scope test and implement if appropriate a model of care based around a Day time Hospital between 8.00am and 10pm and a Night time hospital between 10pm and 8am. The model of care would be managed by a senior clinician leading a multiprofessional outreach team. It is anticipated that this team would cover the hospital both night and day for emergency care as a core team. One of the challenges of the pilot would be to finalise the appropriate skill mix to ensure that the right balance of competencies is available to meet the presenting medical and surgical needs.

Milton Keynes General will deliver WTD 2009 compliance by scoping, testing, developing and implementing, where appropriate, changes in its approach to emergency care through:

• New pathways of care
• Developing a planned element to emergency care
• Developing the role of technology in supporting new ways of working for example iBleep
• Workforce development
• Cultural change and leadership.

The pilot is expected to be complete by August 2009