Achieving EWTD Compliance at Royal Free Hampstead NHS Trust

From 0 to 93 in six and a half years.
By Gareth Jones, head of HR (medical workforce)
Place: The Royal Free Hampstead NHS Trust, London.
Start time: June 2002.
Junior doctors: 450.
EWTD compliance rate: 0 (approx).

78 months later, in December 2008, the Trust reported EWTD 2009 compliance of around 93%. Crossing the distance between the two was quite a journey.

The project began as a 'desperate' attempt to achieve New Deal compliance in time for August 2003. A flurry of activity in separate departments had resulted in little more than increased junior doctor numbers, a soaring wage bill and much tinkering around the edges of the real problem, so a more radical plan was in order. The decision was taken in January 2003 for a Hospital at Night (HaN) model, both because it seemed the only route to securing compliance without compromising patient safety, and because it enabled achievement of EWTD 2004 at the same time as New Deal, in August 2003.

There was only one problem. HaN was a great concept, but there were (then) no real road maps for how to get there. There were some pilots, but they were nowhere near being advanced enough to deliver learning benefits in time. What to do? The only option was to grab what little learning there was (Great Ormond Street, we thank you) and to make the rest up as we went along - consulting, consulting and consulting, but with the power of persuasion, would everyone buy into the concept? Of course not. Life's not like that. But with the CEO and the Medical Director on board, a clinical champion and a seat on every essential decision making body, the project got onto everyone's agenda early on, and by getting up everybody's noses, we made sure it stayed there (on the agenda, not up the nose).

So, with much wailing and gnashing of teeth, HaN was born at the Free on 28th July 2003. With it came compliance with the first round of the EWTD. Did we get everything right first time? Of course not. Almost immediately, flaws and problems with the model became apparent (too many doctors, no real leaders), although not at the expense of patients. By October, we were already into HaN Mk II, and every rotation date brought forth further nips, tweaks and tucks as the system grew ever more refined (fewer doctors, better integration with nursing, putting a nurse in charge - strangely, all of these changes were in the original model but were rejected by the more cautious elements - until the evidence of the need was overwhelming). By mid 2005, nobody was seriously suggesting we go back to the old way of working - HaN was here to stay and the only question was how to move onward to EWTD 2009.

If a week is a long time in politics, then five years is an eternity in the NHS. Keeping the project alive from 2004 to 2009 was surely too much to ask. Keeping the foot on the pedal and just enough petrol in the tank, the project team (refreshed by the introduction of new blood as the old hands collapsed in exhaustion) continued hanging on to that vital seat at the top table, securing the support of the next CEO and Medical Director and once again demanding a place on those agendas. The persistence paid off, the trust again set a target of compliance twelve months early. D-Day: 1st August 2008.

With HaN having already delivered most of the benefits we were going to get, the solution this time had to be local - this is not a 'one size fits all' solution.

Out went standardised rotas with doctors rolling around the changes; in came ‘bespoke’ rotas, drawn up around individual and firm commitments and pulling it all together in a seamles whole. Matching doctor time to clinical need, taking advantage of weekly 'down time' to slice useless hours out of rotas, the hours began to tumble.

A few hard choices had to be made, a few tough issues needed to be ironed out, and yes, the ocasional injection of nursing or other resources didn't hurt either. But by June 2008, every department had a plan in place and on 1st August 2008, the switch was flicked and EWTD compliance became a reality.

Did it work?
Well, almost. That's why it's only 93%. But the departments whose plans failed still have time to come up with the goods, with the added advantage of looking at how the others did it, and all of them are telling us they’ll be there by April 2009.

So what have we learned?

• Rule one: never give up. Keep banging on those doors and eventually, somebody has to open them. When they do, be persistent and do not give up until you get a positive result
• Rule two: do whatever it takes to get your item on the relevant agendas - and stay there
• Rule three: there are no rules. Every department is different, and you need the solution that works for each particular case.

But never forget there is a solution that will work, it just takes a lot of persistence and hard talking to find it.

With thanks to all who contributed to the success of the Royal Free EWTD Project, but especially Mark Vanderpump, James Lane, Simon Porsz and Adrian England.