10.1576/toag.10.2.107.27399 www.rcog.org.uk/togonline Experiences of a 24-hour resident consultant service Author Simon Edmonds / Keith Allenby Key content: The Royal College of Obstetricians and Gynaecologists supports the Department of Health recommendation to increase consultant presence outside current working hours. Resident, 24-hour consultant cover exerts considerable pressure on staff. Whether permanent consultant presence improves standards of care is unclear. Learning objectives: To explore the relationship between evidence in support of a permanent consultant presence and pregnancy outcomes. To appreciate the advantages, disadvantages and practical considerations of 24-hour resident consultant cover. Ethical issues: Is it possible to balance improvements in the standard of maternity care with potential detrimental effects on NHS staff? Keywords resident 24-hour consultant cover / shift work / standard of care / work life balance Please cite this article as: Edmonds S, Allenby K. Experiences of a 24-hour resident consultant service. The Obstetrician & Gynaecologist. Author details Simon Edmonds FRCSEd MRCOG Consultant Gynaecologist Department of Gynaecology, Benenden Hospital, Cranbrook, Kent TN17 4AX, UK Email: simon.edmonds@benenden.org.uk (corresponding author) Keith Allenby MRCOG FRANZCOG Clinical Director of Obstetrics and Gynaecology Department of Women s Health, Middlemore Hospital, Hospital Road, Otahuhu, Auckland, New Zealand 107
The Obstetrician & Gynaecologist Introduction Improved recruitment, retention and expansion in our specialty is required if all the recommendations from the Confidential Enquiries into Maternal Deaths in the United Kingdom, 1 the National Patient Safety Agency (NPSA) 2 and the Royal College of Obstetricians and Gynaecologists (RCOG) working party report, Towards Safer Childbirth, 3 are to be implemented. A significant goal of these reports is to identify the need for an increased presence of senior staff in the hospital outside the current working week. The 2004 UK Department of Health publication, Standards for Better Health, 4 mirrors these goals and aims to develop a safe and high standard of care within the National Health Service (NHS). The RCOG supports these recommendations in its recent publication, The Future Role of the Consultant. 5 This document recommends the implementation of extended consultant delivery suite service and suggests that a permanent, resident consultant be available at all times. In units with more than 6000 births per year, permanent consultant cover must be implemented by the end of 2008, while in units that have more than 4000 births per year this must be achieved by the end of 2011. The implications for workforce planning and future consultant recruitment are being addressed by the RCOG and it should be commended for the proactive approach that it is taking in tackling this difficult problem. Furthermore, the Hospital at Night study 6 has confirmed that in obstetrics the level of activity is the same throughout the 24-hour period: a good reason to provide the same level of cover at night as is currently provided during the day. However, even though the 2006 NPSA report 2 identifies that incidences of severe fetal distress are more likely to occur after midnight than after 08.00 hours, there is a lack of evidence to confirm that these events are reduced following the introduction of a 24-hour resident consultant. In addition, are staff providing this resident service willing to change to a working pattern dominated by a shift system of days, nights and weekends living in the hospital? This article discusses the introduction of a 24-hour resident consultant rota at a hospital in New Zealand, where the authors worked, having both previously qualified and trained in the UK. The site and staff numbers Middlemore Hospital is a large teaching hospital in the south of Auckland, New Zealand, serving a socially disadvantaged population of mainly Maori, Pacific Island and Asian women, with 7500 deliveries per year. The women s directorate previously provided resident consultant cover for 80 hours per week, which was increased to 24-hour resident consultant cover (168 hours per week) in September 2004. The 12 consultants (7 full-time, 5 part-time) each took part in an equal number of on-call shifts. The consultants were split into 4 teams of 3, who between them covered a regular daytime and evening shift each week in addition to a daytime shift at weekends once every 12 weeks. The resident nights, 22.00 08.00 hours, were covered on a rolling 1 week in 12 basis, with an average of 2 5 phone calls and 1 5 episodes of direct patient contact per night. The weekly job plan of one of the full-time consultants is presented in Table 1. Other out-of-hours medical staff members included a senior house officer who saw 5 10 acute gynaecology admissions per night and a single registrar of variable grade. New Zealand medical employment in hospitals does not follow the UK model as set out in the current NHS consultant contract. 7 For comparison, however, the terms direct clinical care (DCC) and supporting professional activities (SPA) are included in Table 1 to allow readers to compare this timetable with the NHS model, which currently allows for 10 programmed activities (PAs) of 4 hours each per week, giving a total of a 40-hour week. Of these, 7.5 PAs must be used to provide direct clinical care. This includes clinics, theatre, labour ward, administration and on-call duty. A further 2.5 PAs are used for supporting professional activities, including research, educational meetings and teaching. In this timetable, no time was given for administration, ward rounds or weekends and nights on call. Resident nights were paid separately, in addition to the basic salary. Table 1 Weekly consultant job plan of lead author, Simon Edmonds Shift hours Monday Tuesday Wednesday Thursday Friday 09.00 12.30 Colposcopy clinic Antenatal clinic Departmental meeting/ Gynaecology clinic Labour ward (1 DCC) (1 DCC) 1week in 3 labour ward (1 DCC) and emergencies (0.6 SPA/0.4 DCC) (1DCC) 14.00 17.30 Alternate weeks Alternate weeks Labour ward and Theatre Labour ward SPA/theatre SPA/colposcopy clinic emergencies (1 DCC) 1week in 6/SPA (0.5SPA/0.5 DCC) (0.5SPA/0.5 DCC) (1DCC) 5 weeks in 6 (0.2 DCC/0.8 SPA) 17.00 22.00 Labour ward 1in 2 resident (0.5 DCC) DCC = direct clinical care; SPA = supporting professional activities 108
Based on the job plan in Table 1, consultants provide at least 8.1 DCC sessions, excluding administration, ward rounds and weekends and nights on call. An equivalent NHS contract would require payment for at least 12 PAs for this level of work. Results Advantages The level of care subjectively improved, with better organisation, planning and critical assessment of emergency cases (Box 1). The midwifery and nursing staff felt safer and better supported, particularly at night. There were many more opportunities for one-to-one training with junior staff, not only in surgical skills but also cardiotocograph interpretation, labour ward management and staff planning. The majority of consultants were generally happy with the principle of this system, as it allowed planning of other clinical activities for up to 3 months in advance without night-time work, and weekend work only every 6 weeks, alternating between days and nights. Disadvantages Despite this extra presence, there were no statistically significant changes in either caesarean section rates (although historically, the department has a consistently low rate of 16 17%) or mean length of hospital stay. The most common complaint was the recovery period of only 3 days and the feeling of general exhaustion during the week (Box 2). Adjustment to daytime sleeping, particularly for those with young families, proved difficult. Some senior staff also felt that they were performing jobs more appropriate to the skills of a registrar, particularly when the latter were busy with an operative delivery, although the appointment of a two-tier registrar system in 2006 reduced this work. Another effect of night-time consultant cover is consultant unavailability for elective services during this time. Consultants in New Zealand are entitled to 6 weeks leave, 2 weeks continuing medical education leave and 2 weeks audit leave (rarely taken). An additional 4 5 weeks per year of nights means up to 15 weeks per year when a consultant is not available for elective services. Those consultants with private practices also voiced their unhappiness at the disruption to this part of their working week. This was less of an issue than childcare for female staff, especially if they were part-time, as normally they would perhaps work 3 days per week, but on the week of nights may require 5 days of childcare to allow them to sleep. Improved level of care Midwifery and junior medical staff feel less stressed Smoother running of the labour ward Better supervision and training of trainees Continued hands-on experience for the consultant Constant presence of an immediately available consultant (improved patient safety) The need for rapid return of the consultant to hospital in an emergency situation is removed (improved consultant safety) Consultant s family are disturbed less frequently by telephone calls at night Salary enhancement Discussion Compatibility between work and family life There has been a steady increase in the proportion of female trainees in obstetrics and gynaecology. The 2002 RCOG Trainees Committee Survey of Training 8 found that 44% of the workforce was female with only 35% of trainees planning to work full-time in the future. The female proportion of the workforce is now rumoured to be closer to 70%. In the past, the RCOG has encouraged women to remain in the specialty by introducing flexible and part-time training, with over 15 20% of trainees currently in flexible training posts. 9 Both sexes are becoming more aware of the importance of a good work life balance. This in itself has a profound effect on staffing levels and suggests an even greater need for consultant expansion, not only to provide more people for cover but also to improve the working lives of current consultants. One commitment of the NHS Plan 10 was to invest in NHS staff and this has been highlighted in the Improving Working Lives Standard, 11 published by the Department of Health in 2000. This publication recognised that: Improving the working lives of staff contributes directly to better patient care through improved recruitment and retention and because patients want to be treated by well-motivated fairly rewarded staff. Shift and night-time work, however, place an extra burden on obstetricians, particularly women, who may wish to opt out of regular emergency cover. The RCOG has also suggested that emergency cover should finish for any obstetrician over the age of 55. 5 This loss of a number of experienced senior No evidence of changes in operative delivery rates or length of hospital stay Inadequate remuneration Chronic tiredness Consultants performing inappropriate tasks Poor accommodation and food Lack of registrar independence Lack of elective continuity Decreased elective efficiency Box 1 Potential benefits of resident cover Box 2 Potential disadvantages of resident cover 109
The Obstetrician & Gynaecologist obstetricians results in a significantly reduced workforce to provide the resident cover, at a time when a shorter length of training and a reduction in hours leaves newly qualified consultants with less experience in comparison. Financial implications The financial implications were significant. The New Zealand consultant contract is a nationally approved multi-employer collective agreement. This agreement did not cater for resident consultant nights and, therefore, separate negotiation took place with the Association of Salaried Medical Specialists. The rates agreed were effectively double time (on top of the annual salary) at all times when resident and on call. The European Working Time Directive The European Working Time Directive 12 aims to protect employees from working excessive hours and limits the employee to an average of 48 hours per week by law. A challenge in the European courts in 2000 13 also confirmed that all hours resident at the hospital, even if spent sleeping, are to be counted as part of this total. The RCOG is in favour of permitting consultants to opt out of these restrictions, if they do so voluntarily, without prejudice from their employers. We believe, therefore, that a minimum of 12 consultants under the age of 55 is required to provide 24-hour obstetric cover (as in Table 1). This gives a reasonably acceptable job plan that allows the clinician to continue with non-obstetric emergency-related interests such that they are not spending all of their sessions providing on-site, out-of-hours cover. For this to occur at current staffing levels, there would need to be an increase of up to 20% in the current workforce numbers in the UK, a target that cannot be reached at the present rate of expansion in the financially poor NHS. The will of the workforce The 2002 trainees survey 8 assessed trainees opinions about the future of obstetrics and gynaecology. Although 76% of respondents agreed that consultants would have resident on-call commitments, only 39% said that consultants should have them. This suggests that most trainees felt this was inevitable but the majority did not feel that they should have to provide cover. Until pilot studies confirm that maternal and perinatal morbidity and mortality are significantly reduced with 24-hour consultant presence, there will continue to be genuine unease and dissatisfaction among current trainees and consultants that they may have to provide resident obstetric cover. This will only worsen if changes are forced upon consultants and their job plans are significantly altered to provide obstetric cover to the detriment of their other interests. Summary The RCOG has set out its vision for the role of the obstetrician in the 21st century. 5 The aim is to improve the safety and care of women. A significant change for the current workforce will be the provision of 24-hour on-site consultant care. Although there were numerous subjective positive results following the introduction of resident cover at our hospital, there were few objective changes in pregnancy outcomes, particularly in relation to operative delivery or length of stay. Further objective evidence regarding the benefits of resident consultants, particularly in relation to patient morbidity and mortality, is required if the current workforce is to embrace this concept of working. Job plans need to be appealing to new consultants and appropriate financial compensation for those working unsociable hours is necessary. Designated rest periods must follow duty and there should be on-site accommodation appropriate to the experience and seniority of the staff present. There also needs to be greater involvement of current consultants, who may feel that this change is being forced upon them rather than adopted by choice. Education about the potential benefits of 24-hour cover, particularly in relation to job planning, should be disseminated. We would suggest a pilot study involving four to six hospitals in the UK undertaking 24-hour resident cover, with assessment of the views of those involved and reporting of any changes in morbidity and mortality. This change in our working practice provides an opportunity not only to potentially improve the care given to women but also to adjust beneficially our own working practices and work life balance. This should encourage graduates to join our specialty, otherwise we could suffer a worsening recruitment crisis over the next 10 years. References 1 Lewis G, editor. Why Mothers Die 2000 2002. The Sixth Report of Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2004. 2 National PatientSafety Agency. Improving Patient Safety. [www.npsa.nhs.uk/patientsafety/improvingpatientsafety/] 3 Royal College of Obstetricians and Gynaecologists and Royal College of Midwives. Towards SaferChildbirth. Minimum Standards forthe Organisation of LabourWards. Report of a Joint Working Party. London: RCOG Press; 1999. 4 Department of Health. Standards forbetterhealth: Healthcare Standards forservices underthe NHS - A Consultation. London: DH; 2004 [www.dh.gov.uk/en/consultations/closedconsultations/dh_4082361]. 5 Royal College of Obstetricians and Gynaecologists. The Future Role of the Consultant. A Working Party Report. London: RCOG Press; 2005. 6 NHS Modernisation Agency. Findings and Recommendations from the Hospital at Night Project. London: NHSMA; 2004. 7 Department of Health. National Health Service Hospital Medical and Dental Staff and Doctors in Public Health Medicine and the Community Health Service (England and Wales): Terms and Conditions of Service. Consultants (England). Version 6. London: DH; 2007 [www.nhsemployers.org/pay-conditions/pay-conditions-348.cfm]. 8 Royal College of Obstetricians and Gynaecologists. Trainees Committee. Survey of Training. 2002. London: RCOG Press; 2003. 9 Royal College of Obstetricians and Gynaecologists. Medical Workforce in Obstetrics and Gynaecology. Fifteenth Annual Report April 2005. London: RCOG Press; 2005. 110
10 Department of Health. The NHS Plan: A Plan for Investment, A Plan for Reform.London: DH; 2000 [www.dh.gov.uk/en/publicationsandstatistics/publications/publicationsp olicyandguidance/dh_4002960]. 11 Department of Health. Improving Working Lives Standard. London: DH; 2000 [www.dh.gov.uk/en/publicationsandstatistics/publications/publicationsp olicyandguidance/dh_4010416]. 12 Office of Public Sector Information. The Working Time (Amendment) Regulations 2003. London: The Stationery Office; 2003 [www.opsi.gov.uk/si/si2003/20031684.htm]. 13 Sindicato de Médicos de Asistencia Pública (SiMap) v Conselleria de Sanidad y Consumo de la Generalidad Valenciana [2000] ECJ case C-303/98 [http://europa.eu.int/eurlex/lex/lexuriserv/ LexUriServ.do?uri=CELEX:61998J0303:EN:HTML]. 111