Barnet, Enfield and Haringey Mental Health NHS Trust

A multi site mental health trust that has adopted new ways of working and staff deployment to achieve early compliance against the 48 hour week.

Background

Barnet, Enfield and Haringey is a multi site mental health trust providing services across three London boroughs. There are three main inpatient sites (Edgware, Chase Farm and St Anns hospitals) - each with around 20 SHOs working on call rotas.

The challenge

In order to hit a 48 hour week, the trust faced significant challenges due to the mix of service provided and different rotas in operation. There are a mix of inpatient, community and A&E on call services provided. It became clear that these rotas couldn’t be made compliant in their current format and that a full review of ways of working would be required.

First steps

The first step was to carry out a clear audit of what the doctors were currently doing - looking at their hours, the actual work they were doing and interventions they were making. "This is an absolutely essential first step," explains Dr Marc Lester, WTD lead, "Without clear information on current work you can’t begin to make plans." This allowed the trust to see what rotas were needed.

At the same time, cost pressures also meant that the trust wanted to look at new ways of providing service so the two pieces of work dovetailed together – looking at more efficient ways of working that would be 48 hour compliant.

The Chief Executive and Medical Director were engaged in the changes from the start – they helped drive the new system and identify and champion the wider benefits of new ways of working.

Introducing the new systems

Getting support in developing models was extremely important and the trust used the expertise of the local Workforce Development Confederation and Deanery to look at various rota patterns that took into account current and future service provision. "This really helped us look at whether we could bring in compliant rotas in one go or whether we would have to phase changes in," explains Dr Lester, "Ideally we wanted to do things in one change and the modelling helped us see that this was possible."

• In order to move towards compliance, the trust cut to two rotas– one focusing on inpatient and one on community services. The inpatient service was provided on a full shift system (also covering A&E on call duties). The community rota started as an on-call system.

• Initially, there was a 1:11 rota for full shift night working and a 1:11 on call rota for community on call, with appropriate compensatory rest. Subsequently, once workload had been assessed, together with the introduction of a new Crisis and Home Treatment service, we were able to amalgamate both rotas into 1 single in house full shift pattern.

• Two trust grade doctors were recruited and attached to the two on call teams – the same doctor covered the same team which helped build relationships and ensure continuity of care.

• A multi-disciplinary team approach was adopted. A night nurse coordinator acts as gatekeeper to stop inappropriate call outs. The trust avoided the need to recruit a lot of extra staff by carefully reviewing current roles and capacity and enhancing roles of non junior doctors where needed to support the team approach.

• A half hour handover has been introduced as part of the new arrangements and staff are not allowed to leave until handover is complete. Bleeps have also been replaced with mobile phones – there is a handover phone and each doctor also uses a personal phone to ensure contact can be made at all times.

Reviewing the changes

Throughout the process, the staff were consulted and asked for their views on how the new systems might work best. A multi-disciplinary team working party was also formed to give feedback. The doctors made the decision about how the shifts would best work for them in terms or a week on/week off for nights to begin with – after working that system for a while they decided to change to a system of single night shifts, as there were now more doctors on the rota. This also produced a cost saving through less need to employ additional Trust Doctors. This was achievable because the changes to working practice had been staged , allowing staff to get used to them

Dr Lester explains, "There were regular meetings with the junior doctors about how we made this work. They came up with a preferred option of a week on/week off approach to night work. We constantly reviewed things and made changes as the systems bedded in and refinements were made - partly due to workloads, partly down to service changes and partly down to financial pressures. We made sure that staff led the changes and came up with new ideas – you don’t always get things right first time but by working together we made the system work for us."

Outcomes and impacts

The trust is now compliant against a 48 hour week – with many junior staff working significantly less hours than that - but adopting the new ways of working has had other benefits as well.

Standards of patient care have also been seen to have improved with better continuity of care provided by the new rota system. This has been backed up by the results of the National Patient Survey where the trust had a much improved score in terms of patients-doctor relationships. "We think the changes we put in place to meet WTD have been a key driver for this," says Dr Lester, "Our doctors are less tired and it’s a responsible and effective way to work."

The trust has also made significant cost savings by introducing the new ways of working – with savings of around £300k on locum costs being achieved.

Five key lessons from Barnet, Enfield and Haringey.

1. Plan – Audit so you know exactly what you need to cover on a shift. You can work out what you need and where service cover can be combined. This allows you to make key decisions - can rotas be in house or split site for example?
2. Engage - Staff need to be involved throughout in decision making and given choices and options. They need to see WTD as a driver for improving services.
3. Support - Use the expertise of WDC and Deanery in modelling rotas. Tap into expert knowledge that is out there in the service to support you.
4. Refine – You don’t come up with the best model first time every time. Plans need be reviewed and refined over time and flexibility is important.
5. Leadership – Leadership is essential. The engagement and support of the chief executive and medical director helped drive the changes in the trust.

• Dr Marc Lester – EWTD lead