Practical guidance on achieving EWTD compliance

Why we cannot simply increase the number of doctors to make all rotas compliant
There will be increases in the medical staffing in both consultants and training grades, but it is important that these additional doctors are used to deliver increased activity or improved patient care. Recruiting additional doctors just to make all the existing on-call rotas compliant will not be an effective use of financial and human resources. The main reasons for this are:

For many existing resident on call rotas, the intensity of calls is not sufficient to justify moving to a full shift pattern. In these cases it may be possible to provide non-resident on call cover without increasing the number of doctors.

It is unlikely that it will be possible to recruit sufficient doctors at SHO or equivalent level to make all the existing SHO rotas compliant. Small hospitals in rural areas are likely to be particularly vulnerable in relation to recruitment problems.

If these additional doctors are not appointed into bona fide training grades, their posts may not be able to offer satisfactory training and career development opportunities for the individuals recruited.

Such an approach is likely to be at odds with the aims of modernising the service and medical education.

Recommended Process for Developing an Action Plan
The critical issue in relation to EWTD is the provision of out of hours emergency medical cover. Solutions are likely to require a more radical approach involving the following elements:

A thorough assessment of what activities need to be done out of hours and who could do them.

Who can best deliver care? Should it be a doctor or a non-medical practitioner?

If a doctor is needed, what level and type of doctor would be most appropriate to deliver care to the patient?

Are there ways of reducing the likelihood of this activity occurring out of hours?

A clear assessment of the activities that doctors in training need to undertake to meet their training needs. Individual Learning Plans need to be developed which can effectively deliver training objectives within the new working patterns and service models (see section 3 below).

Appraisal of service models to see if there are alternative ways of delivering the service which maintain or improve the quality of care for patients and can achieve EWTD compliance.

Reviewing working patterns for all medical staff – Consultants, Associate Specialists, Staff Grades and Training Grades.

Trusts must ensure that the solutions they develop achieve the dual aims of EWTD compliance and service delivery. It will not be appropriate to achieve EWTD compliance for doctors in training at the cost of failing to meet delivery targets.

What are the solutions? The results of this process will produce different solutions across specialties and type of hospital but are likely to include some or all of the changes outlined below. A national programme of pilot projects has been set up covering a range of different services and approaches. Examples of some or all of the solutions described below can be found in each of the pilot projects. Details of the solutions that are being tested can be found on the EWTD web site at http:// www. doh. gov. uk/ workingtime/

Reduction in the number of rotas There will need to be fewer but more intensive resident rotas supported by on-call cover from home. This will be achieved by:

Cross cover While this may involve sharing cover between related specialties, greater benefits are likely to result from more radical approaches. A number of Trusts, including some of the pilots, are developing central emergency teams or night teams able to provide cover across the hospital. These bring together medical staff from A& E, Acute Medicine and in some cases also Anaesthetics and Surgery as well as non-medical practitioners.

Fewer tiers of cover New non-medical roles are being developed which can work alongside SHOs and PRHOs and in many cases eliminate the need for these tiers of cover. Increasingly, the main tier of out of hours medical cover will be provided by experienced doctors such as Specialist Registrars, Staff/ Associate Specialist Grades or in some cases Consultants.

There are good examples of both cross cover and reduced tiers of cover in the pilots.

New working patterns Simply replacing a resident on call rota with a EWTD compliant shift rota could require an increase in the number of doctors on the rota from 5 or 6 to 8 or more. However, more creative redesign of working patterns can avoid the big increases in staffing that this implies. Examples are given in the pilot project information where, by changing the working patterns of both the Consultants and Specialist Registrars, it is possible to provide resident 24-hour cover with as few as 6 SpRs.

Expansion of staff numbers Underpinning these changes will be the planned expansion in the consultant workforce to enable a move towards a consultant delivered service. Floors and ceilings have been introduced which will allow SpR numbers to expand beyond the 1,000 increase in the NHS Plan to approximately 1,500 and further expansion is being considered. Trusts should build on these increases rather than expanding the number of 'Trust Doctors'.

Large increases in the nursing workforce and the Allied Health Professions have already been achieved and there is a commitment to maintain these levels of growth. These increases in the non-medical workforce together with up-skilling of the Health Care Assistant workforce will support the development of the non-medical practitioner roles required.

Team working Effective use of non-medical practitioners and extension of cross cover will require a move from the traditional consultant firm to multi-disciplinary team working. There are good examples in the pilot projects of night nurse practitioners and other non-medical practitioners working alongside doctors in multidisciplinary teams.

New service models  Many of these changes will be supported by the development of new models of service delivery. In particular, this is likely to involve greater differentiation of services, for example separation of high and low acuity and day and night services, which will allow medical resources to be concentrated where they are most effective. These changes also need to be underpinned by the effective use of clinical networks.

Starting from the premise of the need to maintain local access to services wherever possible and also improve the quality of patient care, the Department of Health advisory framework for configuring hospitals (see section 6 Further guidance) provides guidance on developing service models that also achieve EWTD compliance. It also makes clear the importance of patient and public involvement at every stage in the process.

Use of IT The use of IT can potentially reduce the need for resident medical expertise where this is difficult to provide. Examples include video links into major trauma units to support local emergency assessment of patients, near patient testing, access from home to imaging data, etc. Several of the pilots are using IT to supplement other changes in achieving EWTD compliance.

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Delivering effective medical training under EWTD