As the race to meet the WTD by 1st August 2009 draws ever nearer, hospital trusts are increasingly looking at innovative ways to reduce the number of hours their junior doctors are expected to work whilst still guaranteeing patient safety and training quality for junior medical staff.
Stockport NHS Foundation Trust and Avon and Wiltshire Mental Health Partnership NHS Trust, have both been involved in pilot projects in conjunction with the Skills for Health - Workforce Projects Team
to do just that.
Both trusts had become increasingly aware that in order to ensure WTD compliance by the 2009 deadline, ways of working for doctors in certain specialties would need to change.
Avon’s project, which drew to a close last October, set out to devise new solutions to the workload of its senior house officers (SHO)/F2s. The trust wanted to analyse and change their way of working to establish which tasks could be performed by others and aim to have more than one type of professional to undertake most of the tasks performed by SHO/F2s. The pilot work helped the trust to ‘reprofile’ the work of the SHO/F2s by establishing new rotas, policies and pathways.
“The pilot was one of the things we used to help ensure that our juniors would meet the requirements of the WTD,” said Christine Vize, consultant psychiatrist and director of new ways of working for the Avon pilot. The trust also wanted to reduce the junior doctor callouts to a minimum whilst improving the quality and timeliness of interventions to service users. The project was carried out with safety in mind.
“We started to analyse how we worked. We carried out an audit of all the calls that junior doctors were expected to answer, we looked at our protocols and our triage systems to make sure that doctors would not be called out spuriously and we audited their activity both during the day and at night,” she said.
During the pilot, the trust found that junior doctors were being called out unnecessarily. Dr Vize says the pilot helped the trust to realise new ways of working, including the development of ‘Patient Group Directions’ which allowed nurses who had been appropriately trained to administer certain medications so that the trust’s doctors were not called on to prescribe and sign off all drugs, thus improving the quality and timeliness of interventions. She said: “Ultimately, one of the main things we learnt from the project was that junior doctors’ time could be used more efficiently and we have taken steps to address that and made changes to optimise their efficiency for the benefits of service users.”
Dr Vize says that she would encourage all trusts to carry out a detailed audit of the working patterns of their junior doctors to inform more efficient practices to help become WTD compliant. She adds that it is important for trusts to implement changes in the round, she said: “Any plans or decisions around changes in working practices should not be made in isolation as changes made in one area of the service are likely to have a direct impact on other roles and services that already exist in the trust.”
In Stockport the pilot project was used to look at how to extend a urological hub and spoke model for the provision of services to patients in Macclesfield. Day case and outpatient services were to remain at Macclesfield district general hospital and all inpatient and emergency services were to be transferred to Stockport’s Stepping Hill hospital. However, at the start of the project rotas for Stepping Hill hospital meant that the model was not feasible. In its previous form staffing levels meant that a middle grade rota could not be supported. Instead, consultants joined the rota to make it a 1:5 on call rota, not something that was WTD compliant.
During the project the trust decided to introduce specialist nurses to extended roles both at the Macclesfield site and in community settings in order to release existing medical staff for appropriate training as well as providing more effective out of hours cover. Consultants at Stepping Hill also changed their rota to include the Macclesfield site. Having identified gaps in capacity that needed to be filled in order to become WTD compliant to incorporate the Macclesfield site, Stockport recruited a clinical fellow and two staff grade doctors into their middle rota. This allowed the trust to move from a 1:5 rota to a 1:6 rota. The hospital is also set to recruit an additional specialist registrar to take the rota to 1:7 and is aiming to become WTD compliant a year early.
Lynn Nuttall, project lead for the Stockport pilot says that not only has it benefited patients and staff, it has meant that the trust has been able to ensure that its urology service is more ‘robust’, she said: “I would definitely recommend it as a model for other trusts to think about using and it could be rolled out to other services and specialties. For certain trusts that are vulnerable to reorganisation this hub and spoke model can help them whilst at the same time ensuring WTD compliance.”
Lynn also feels that it is of paramount importance to get clinical involvement at an early stage. Stockport enlisted its clinical director Stephen Brown as a clinical champion, she said: “Without this the project would not have been successful as it did involve significant change to both the medical and senior nursing team.”
Stephen Brown himself agrees, he said: “The only urology consultant based at Macclesfield was ready to take on a less demanding role and the staff grade doctors were very much in a dead end position so they were keen to expand their experience to progress their careers. When it was explained to them that even though they would have a different on call rota and they would be traveling more, but that they would also gain better training and get specialist recognition, they were happy to change.
“The great thing is that from August 2008, a year early, we will be WTD complaint.”
www.healthcareworkforce.nhs.uk/pilotprojects
Working Time Directive 2009 
