Achieving WTD compliance with geographically closer services

Hub and spoke model - the clinician's view

Redesigning and improving secondary care services which better meet the needs of patients while simultaneously keeping an eye on the Working Time Directive presents something of a challenge for the NHS.

But for one health community, the dichotomy of taking their urology service closer to patient's homes at the same time as meeting junior doctor hours compliance was a test they were ready for.

Stockport NHS Foundation Trust already ran a successful 'hub and spoke' service for urology services across sites in Stockport, Tameside, Glossop and the High Peak. When it agreed to take the model further still, it meant testing a pilot which extended it to include Macclesfield District General Hospital.

Calling Time spoke to consultant urologist and clinical lead for the urology project Dr Stephen Brown at Stockport NHS Foundation Trust to learn more.

"We'd been working with our hub and spoke model across Stockport, the High Peak and Tameside and Glossop for more than ten years and we knew it worked well.

"Our outpatient and one-stop clinic services - the spokes, if you like - combined with the inpatient service at Stepping Hill - the hub - to develop into a tried and tested formula for a population base of over 600,000 across both rural and city areas, "Which isn't to say setting it up wasn't without its problems when we started, but we learned a lot of lessons along the way. When the chance to test the model that little bit further, by including Macclesfield as well, we thought it was a real opportunity.

That opportunity came about when one of the two urology consultants at Macclesfield left, leaving one consultant and two middle grade doctors.

It presented a key challenge for the trusts - how to move towards readiness with the 48 hour week alongside competing priorities in the health service.

"Between the teams, we realised that while the patient numbers were big, they weren't big enough for two separate services to achieve both WTD and clinical compliance. But if we combined the teams, bringing across the middle grade doctors to Stepping Hill, adding to that mix consultants with sub speciality interests and looking at alternative provision with senior nursing staff based at Macclesfield, we thought we might have a workable solution.

"We agreed that centralising staff would make it easier to design rotas that were compliant. We also knew that multidisciplinary working was essential."

The pilot started in May 2006. And straight away the Macclesfield middle grade doctors were taking part in the rota and in theatres, helping to increase throughput. They were also able to start receiving input from the sub-specialist doctors. At the same time, a specialist nursing team, started to run nurse-led sessions from Macclesfield.

And all the inpatient work went to Stepping Hill, where there was already a comprehensive urology service which included major pelvic cancer laparoscopy and female urology.

"It started really well, and has continued to work really well," adds Dr Brown.

As to why the pilot has been so smooth and straightforward, Dr Brown is clear about its success.

"It's down to a good team of people with good communication across the sites. Everyone has been friendly and accommodating and it's generated an approach where we've talked about any problems and issues early on. We very much tackled this as a team.

"The success is certainly down to the team - senior managers across surgery, operations, modernisation, finance and human resource.

"We also spent a lot of time in the first nine months going out and talking to people - to locality meetings, to the PCTs and overview and scrutiny committee meetings. We knew we had to explain the clinical benefits to having one specialist centre across the areas."

Dr Brown also admits that the lessons learned when the Stockport team started the hub and spoke model with Tameside and Glossop in 1995 were invaluable. "We took the lessons off the shelf and were able to use them for the expanded service with Macclesfield."

The opportunity to redesign also meant the project team was able to look at working practices and to reshape them where needed and to introduce regular central meetings where clerical, nursing and clinical staff come together.

"It works really well," says Dr Brown. "We often have lunch together afterwards. It's all good team building."

As to WTD compliance? The hub and spoke model has two specialist registrars, a registrar, a research fellow and two staff grades. And a further specialist nurse has been recruited to strengthen the Macclesfield senior nursing team.

"We're just finalising our 2009 compliant rota which will mean we need to advertise for a further staff grade, but once we've got that in place we'll have achieved the ultimate goal of the project."

The team is now looking at working more closely with the PCTs and GP practices in Macclesfield.

"We already work as a successful multi-site model. We need to look at how we can take this to other settings so we can continually improve the continuity of care. And in turn, this will help us to focus on our future workforce planning, particularly outpatient provision."

Dr Stephen Brown and his team delivered an engaging workshop session at the Showcasing Early Compliance conference held on the 6th November.