Case Study - Guy's and St Thomas' NHS Foundation Trust

Taking Care 24/7

The main focus for Guy's and St Thomas' NHS Foundation Trust was attempting to separate 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 to comply with European Working Time Directive a year ahead of time by August 2008.

The trust 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.

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These teams can access senior medical advice immediately, 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.

Ultimately, this is about keeping the patient safe.
Diana Hamilton-Fairley, deputy medical director

Before implementing the changes the trust audited and analysed the working patterns and core activities of junior doctors in 25 specialties. It showed that while the majority of junior doctors' time was spent on direct patient care, they spent a fifth of their time on administration. It also showed that more than five percent of junior doctors’ time was spent on minor procedures such as taking bloods and IV cannulations.

From the audit the trust concluded that employing more doctors would not help them meet the directive. It 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 EWTD their time needed to be better used.

Diana Hamilton-Fairley, deputy medical director at the trust 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.

"Also, this is when we introduced the clinical practictioner role. 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 EWTD compliant in all areas. Dr 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.

Dr Hamilton-Fairley said: "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."

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