Royal Surrey case study clinical support worker

In Mid 2006, the Royal Surrey County Hospital started a project to facilitate compliance with the Working Time Directive 2009, in order to reduce junior doctor hours.

The project aims to sustainably reduce hours and the intensity of junior doctor workload to achieve compliance, one way they are doing this is through the extension of roles for non-medical staff.

Read about the Royal Surrey pilot >>>

Royal Surrey County Hospital NHS Trust project manager, Dr Erica Heppleston, outlines how the trust has started to recruit pilot clinical support workers and what has been learned from the process.

"In our WTD 2009 project we welcomed the opportunity to create a new pilot role to help reduce junior doctor hours.

Our hospital 24/7 non-emergency multidisciplinary committee is investigating a six month pilot of clinical support workers (CSWs) on a medical and surgical ward. We aim to contribute towards sustainably reducing junior doctor hours whilst creating new opportunities for other staff. We considered various existing models of assistant - variously described as physician's assistant or medical technical assistant. We then created a new post which fitted our needs across acute and elective care. This article discusses our experience in setting up this role, with a particular focus on the recruitment process.

What were the initial steps undertaken?

A job description and proposal were prepared and presented to the Hospital 24/7 project board. The pilot gained wide support as an initiative to support junior doctors.

Job description

The job description clarified the clinical and administrative aspects of the post, linked into providing support to junior doctors. Determining the post's reporting lines proved difficult as we tried to balance the clinical and administrative aspects of the role. We initially suggested direct reporting to the specialty service manager (consistent with some of our existing technicians) and a dotted line to the nursing ward manager (for clinical supervision).

Subsequently, we have changed the post's clinical reporting to the medical director for the duration of the pilot, ensuring senior level support to get the role established. The clinical reporting line requires further review as the pilot progresses, to determine the best structure for our hospital if the pilot is successful and more CSWs are employed across different wards.

The job description was presented to the Agenda for Change Panel for approval, gaining band 3 rating. This provides scope for existing band 2 workers, for example, healthcare assistants, to apply for the role and gain further training, opportunity and promotion.

Proposal

The pilot proposal, presented to the Trust Executive Management Committee, summarised the pilot's benefits, goals, and anticipated costings. Our commitment to training was supported by a designated training budget, giving us scope to tailor training to both the applicant's background and the requirements of the role (clinical, information technology, administrative). The proposal received formal approval with support now in place at trust director level.

Securing funding

After obtaining senior commitment within the trust, we gained the support of our project sponsor, Skills for Health - Workforce Projects Team. During the project's midpoint review, we held a strategic meeting with representatives from the Workforce Projects Team and it was agreed that we could use some of our pilot funding for this purpose. Conscious of the Workforce Project Team's requirement that the applicants be appointed as soon as possible to facilitate evaluating the pilot's effectiveness before the project's endpoint in March 2008, we developed a firm recruitment strategy.

An active recruitment strategy

We decided to actively market the post to certain target groups to whom we wished to sell the role, for example, existing healthcare workers wanting to progress to new opportunities and those hoping to gain clinical experience before applying for places at medical school.

Selling the pilot posts internally

To maximise our chances of internal applicants applying we advertised the post internally and liaised directly with departmental directors and managers to circulate details among their team members. In particular, we liaised closely with pathology so that our existing phlebotomists could be made aware of the new opportunity.

Reaching future applicants at medical school and other healthcare professions

The NHS Jobs advert highlighted that the post provided a unique clinical training and work experience opportunity for applicants hoping to train as doctors or nurses in the future. It was a challenge to reach potential applicants to encourage them to apply for the posts.

To overcome this, we contacted representatives from local universities and medical schools to discuss the roles with them, with a view to engaging their support to market the role to their future potential applicants. We were delighted to receive warm responses to this approach from both a nearby medical school and neighbouring university. It was rewarding when applicants phoned in to obtain more information on the posts. Close liaison with local education providers also contribute towards our project's - and the hospital's - goal of enhancing links with our wider community.

Developing a tailored training programme

A challenging aspect of the process has been developing a tailored training programme for these new posts, reflecting the differing clinical skills mix of potential applicants.

Some of the complexities identified through the training plan preparation process have yet to be resolved, for example, we have been unable to determine a practical means of allowing CSWs to insert intravenous cannulae; owing to broader factors surrounding the use of saline flushes by non-qualified staff members and the application of patient group directions. As the pilot progresses, we will review our training plan to determine its effectiveness as a model for future potential trainees.

Was our recruitment and induction strategy successful?

We are pleased that we were able to recruit our pilot CSWs in a timely manner, and that they have been able to start work with a comprehensive schedule which staggers their clinical and administrative training.

The job advertisement reached a wide range of applicants and this was evident from the candidates from whom we were able to shortlist. The high standard of applicants was also helpful in terms of assessing the future sustainability of the role. Whilst it will take some months into the pilot before we can fully evaluate the success of our strategy, we are confident that we have learned from the initial stages of the project.

What did we learn from this process?

• Executive level and clinical sponsorship is key to establishing extended roles across clinical boundaries.
• Flexibility to change reporting lines and responsibilities allows learning to be incorporated into the roles during the pilot and beyond.
• A designated training budget and plan is key when trialling a new role.
• Secure funding early, and agree any caveats in advance.
• Actively marketing a post through new channels can widen the applicant pool.
• Engage trainers early, adapting existing hospital training structures where possible.

Dr Christopher Tibbs, consultant gastroenterologist and medical director, Royal Surrey County Hospital NHS Trust, offered several key tips and areas of learning to Calling Time readers in implementing a successful WTD 2009 implementation project.

Challenges of the project and how they were overcome

Maintaining momentum over the longterm

• Project board with clear objectives and regular monthly meetings
• Mid project review against initial objectives, to revise as applicable
• Designated project manager
• Commitment from senior clinical and non-clinical staff.

Linking in junior doctors

Presentation to junior doctors on the project

• Inviting junior doctor representatives on to each workstream
• Linking in to national initiatives - project manager representation on the National WTD 2009 Junior Doctors Forum.

Determining sustainably how to reduce junior doctor hours

• Review of rotas is multidisciplinary - involving clinicians, specialty managers and project team
• Trialling new rotas early - to enable changes to be revised if needed
• Piloting the transfer of tasks to other clinical staff - clinical support worker six month pilot (one medical, one surgical); nurse led surgical pre-assessment workstream.

The benefits of the project to the trust

Maximises chances of compliance by August 2009

• Determining rota and working practice solutions in advance of the deadline maximises the chances of being WTD 2009 compliant by the due date.

Development opportunities for other staff groups other than junior doctors

• Transferring tasks to other clinical staff groups provides an opportunity for other professional groups to gain new skills.

Applying the learning to future projects

• Learning about the process involved in participating in long-term projects (such as resource planning requirements) can be applied to future national pilots / projects.

Junior doctors gain audit and governance skills

• Participation in project workstreams provides junior doctors with the opportunity to gain experience in audit and clinical governance which could be of future use in their careers and to support their portfolios.

Lessons learnt from the project

Each specialty requires a tailored solution to reducing junior doctor hours

• Cross-cover between specialties for on-call work is complex and is often impractical even at very junior grades, due to specialty specific training requirements. A generic approach is not typically feasible.

The reduction in doctors hours from 56 to 48 provides a major challenge

• A sustainable solution is yet to be developed across all specialties and training grades, due to the significant impact of losing eight junior doctor hours per week. Providing staff with ‘zero hour days' is impractical in terms of patient continuity and teamworking and further reduces opportunity for training - a key concern of junior doctors.

Unique approaches to obtaining specialist clinician input to the project are beneficial

• The acting director of medical education agreed to act as an advisor to the project board linking in with the project manager. This removed the need to attend meetings on specific dates but enabled the board to benefit from specialist guidance on matters regarding education and training, an integral part of junior doctor development.

Busy clinicians face challenges when balancing project work with clinical work

• Locum cover is not always practicable for covering senior staff working on the project for blocks of time - certain senior line roles are often best covered in-house, and this can place further strain upon other team members.

Estimates of resources applied to the project should be prepared at the project outset and regularly reviewed

• The major component of many projects is staff resource - whilst a precise quantification of resources required is not always possible at the outset, an initial projection is useful to enable the trust and individuals to assess whether it is practicable to undertake a project
• Regular review of forecasts assists determination of the project's impact on the trust, and also whether future projects are likely to be practicable.

• Clinical Support Worker job description
• Proposal for the introduction of Clinical Support Workers
• Clinical Support Workers training plan 2007