A number of organisations are attempting to meet the Working Time Directive ahead of the 2009 deadline. Guy’s and St Thomas’ NHS Foundation Trust is one of them - hoping to have met the directive this summer.
The main focus for the trust in attempting to achieve this is separating acute unplanned and unpredicted care from planned care. The Taking Care 24/7 project was set up by the trust to look at what it needed to do specifically to achieve the directive ahead of schedule by August 2008.
To do this the trust has introduced new non complex planned and unplanned care pathways with rapid access to diagnostics and therapies in an attempt to prevent patients being admitted to hospital. The pathways are managed by a mixture of non medical practitioners, physiotherapists and pharmacists, who work with physicians’ assistants and clinical assistant practitioners.
These teams can access senior medical advice immediately, if they need to, whilst in practice they help to substantially reduce unnecessary administration previously taken up by doctors.
The teams can also refer on to complex care teams, led by senior doctors, when needed. Under the new system, junior medical staff are given training in non complex planned and unplanned pathways, as well as being exposed to emergency cases under close supervision. As they progress, junior doctors join complex care teams and finally become senior members of the teams.
The trust’s aim ultimately is to make sure that they have the right people in place to treat patients at the times when they most need care, and to look at whether some tasks can be performed by staff other than doctors.
Before implementing the changes the trust audited and analysed the working patterns and core activities of junior doctors in 25 specialties.
For each speciality a report was produced to provide:
An overview of information on the area, and comparisons with the trust as a whole and with other specialities
An overview and detailed data showing the amount of time spent by junior doctors on different activities
An initial analysis of the data to generate discussion within the speciality and between the project team.
The audit showed that while the majority of junior doctors’ time was spent on direct patient care, on average junior doctors spent a fifth of their time on administration, with Foundation Year 1 doctors spending almost 35 percent of their time on administrative tasks. The administrative tasks were split into different types of work, for example organising admissions or theatre lists, or searching and chasing up test results or notes. It also showed that more than five percent of junior doctors’ time was spent on minor procedures such as taking bloods and IV cannulations.
Specialities within the trust have a detailed snapshot of the demands on their junior doctors.
Over the last few months the trust has considered the appropriateness of some of the tasks doctors are doing, as well as the potential to develop new roles and reorganise many of our processes to improve efficiency and reduce waste.
From the audit the trust concluded that employing more doctors would not help them meet the directive and instead they had to identify the skills that needed to be replaced as doctors’ hours are reduced.
The organisation also realised that the way that doctors work needed to be reorganised in order make better use of their clinical skills.
Diana Hamilton-Fairley, deputy medical director says that all hospitals struggle to meet the directive when elective and day case patients need to be admitted to hospital.
“We have always had a critical care team at the trust but patients have to be quite sick for that, the introduction of the new site nurse practitioner fills that gap,” she explains.
Dr Hamilton-Fairley says the audit found that most junior doctors were doing an “enormous amount of administrative as well as clinical procedures” and the trust soon realised that if they were to meet the directive their time needed to be better used.
“This is when we introduced the clinical assistant practitioner role,” she says, “They are now an integral part of the ward they have advanced clinical skills and can take the routine day to day stuff off junior doctors.”
The Guy’s and St Thomas’ project appears to have proved successful so far to the extent that the trust is now Working Time Directive compliant in all areas. Ms Hamilton-Fairley gives much of the credit for this to the site nurse practitioner role which she says in general enables a quicker direct referral to the most appropriate person. Challenges do remain however, for example, how to ensure the necessary skill set is mainlined by locum cover when staff are on leave.
The trust has also introduced the new post of surgical assistant in cardiothoracic surgery in a similar way as the ward based clinical assistant role. Surgical assistants are trained to carry out procedures such as vein harvests and they assist surgeons as well conducting ward rounds with registrars.
“Ultimately, this is about keeping the patient safe, but the role is working well and we are looking at rolling it out into other surgical specialities,” Dr Hamilton-Fairley says.
She says that the trust are currently analysing every role and looking at efficiency gaps: “Patients in the surgical care pathway now have specific nursing staff to collect them for surgery and bring them back to the ward, which means we are not losing nursing staff from the ward, this is a good model and will help to meet the directive, it is something others can learn from.”
Working Time Directive 2009 
