Securing Future Practice: Shaping the New Medical Workforce for Scotland
4 WHAT KIND OF SERVICE DO WE NEED TO STAFF?
Themes: We learned that: The public expects to be treated by trained doctors who are competent to deliver a safe, quality service. The service should be as local as practicable and based around the patient journey. The profession expects a balance between quality of life and the demands of work.
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23. Scotland spends more per capita on health and personal social services than the rest of the UK. The Scottish Executive recognises that significant reform demands significant investment. It has already committed to increase Scotland's health budget from 4.6 billion to 6.7 billion over the course of the current Scottish Parliament (2003-2007). It is aware that Scottish taxpayers and patients will expect to see service improvements as a result of this investment. But there are challenges. More resources cannot be deployed simply to sustain the status quo - change is necessary and with that evidence that the health spend will be 'good value' with, where necessary, priorities recognised and addressed.
'. . . the supply now and in the future will not meet the demand if we retain current patterns of service delivery. Redesign of the delivery of services is in our view inevitable'. Future Practice, July 2002 |
24. We acknowledge that the service of the future will require changes in medical practice that will influence the shape and structure of the medical workforce. We begin to set these out below.
A service built around the patient
25. The patient journey provides a useful focus for delivering care. Clinicians will need to be made more aware of that journey and their role in ensuring that it is efficient, effective and responsive to patient need. There will be many different kinds of journey across the service. For this approach to be successful then:
where care is delivered locally it must be appropriate, that is:
safe;
of high quality; and
fully supported.
the routes and means for accessing care at all levels need to be understood by patients and clinicians and enjoy the confidence of both. Greater integration of services within multi-professional clinical networks which bridge primary and secondary care will reduce duplication and speed the journey. But open-ended access may not be deliverable in all situations. There are always likely to remain constraints on human and financial resources making it necessary to prioritise services. We are short of doctors, making expansion of services difficult and reform both a challenge and a necessity.
improved access to diagnostic services will build on the doctors' key role in diagnosis and support local services.
A service with defined goals
26. The medical workforce of the future will need to reflect the demands of the service, but what will that service look like? What are its goals? There are some key issues to resolve. These include:
What is the balance between emergency and elective care?
What care should or could not be delivered locally?
How far can teams and care networks resolve these dilemmas?
What is the relationship between specialist care, primary care and integrated care and do these distinctions remain relevant?
The commitment to health improvement.
27. We recommend greater emphasis must be given to the development of general practitioners able to take responsibilities across the interface between primary and secondary care; equally, some hospital practitioners should also take responsibilities across this interface thus leading to a more integrated service.
28. Primary care is first contact, continuous, comprehensive and co-ordinated care provided to individuals and populations undifferentiated by age, gender, disease or organ system". 20
The patient journey of care is wholly within primary care for most episodes of illness and, for the small proportion that reach secondary care, the journey usually begins and ends in primary care. Countries with a strong primary care system have better health outcomes, fewer unnecessary deaths and lower costs than those with poor primary care. 21
29. Emergency care A major challenge is the delivery of emergency primary and secondary care. This is likely to impact more on doctors than on other care staff hence their particular interest in seeing how care is to be provided around the clock. It matters also to the public and patients, who need to have confidence in a 24/7/52 quality acute service. With the limitations on medical staff time this is a powerful lever for service redesign. Decisions on the localities and clinical situations for which triage and transfer arrangements are appropriate must be made on the basis of patient safety, balancing issues of speed of access to specialised medical services against what it will be possible to provide and sustain locally. We recommend that this is addressed urgently and realistically, as in many situations the status quo cannot survive.
'Travel time increases risk for emergency care, but so can lack of capacity, critical mass or experience in a small unit.' Future Practice, July 2002 |
30. Elective care For a major or once-in-a-lifetime planned event, we believe that patients will understand that they may need to travel to access safe, high quality services. Access to such specialist care must be supported by the provision of suitable step-down facilities, where practical, building on the seamless care provided by network teams. Where high standards of care can be assured elective care should be undertaken locally. This will vary from discipline to discipline and within any one discipline from condition to condition all depending upon critical mass of staff, facilities and geography. There needs therefore to be clarity over what care should be undertaken in a 'local' situation. We are conscious that there is no single solution that can apply across Scotland but this is a debate that needs to be had now if we are to understand better the role of doctors in sustaining service delivery. However,
local delivery of all healthcare is desirable but only where it is safe and practical so to do and where there is an adequately resourced and competent team able to deal with the situation; and
the use of protocols and access to expert help from specialised centres (for example through Telemedicine) operating as part of a clinical network should provide essential support.
31.
Remote and Rural Care We recognise that in some areas a locally-based full secondary care service may not be viable both for emergency and for elective care.
Emergency care
- many of the present services in remote district general hospitals will become unsustainable in the near future and will have to change;
- core services are those which need to be delivered 24/7/52 and will require the presence of physicians, surgeons and anaesthetists in the remote centre, integrated with an equivalent team from a larger centre which is prepared to share responsibility for acute clinical care. Such core services would not include, for example, resident consultant run orthopaedic or psychiatric services; but they could include emergency physicians with triage, resuscitation and stabilisation skills for management of the seriously ill patient.
We recommend that 24/7/52 emergency acute care can be sustained in remote district general hospitals if there is a shared responsibility for emergency care with a larger centre.
- in these areas maternity services should be midwife-led;
- there will also be different solutions for out-of-hours care and these could include changed roles for both primary and secondary care doctors; and
- it will not be possible for locally based consultant surgeons to provide 24-hour cover in remote hospitals under the Working Time Regulations.
The health care needs of the population in remote areas may not justify or be able to sustain the current medical establishment. Service provision will not necessarily be met in the same way for each of these remote hospitals but the only way that they will survive will be with significant links to a larger more extensively resourced centre or centres. Such linkages could be:
A lift and run transfer service would rely in part upon national emergency services such as air ambulance being available to supplement surface transport when needed. In the year 2002/3 there were approximately 3000 air ambulance transfers in Scotland at an average direct cost per mission of 2,531: 75% for emergency and urgent cases; and 25% for planned transfers. Air ambulance services are currently being revised and it is anticipated that there will be a significant level of redesign to take account of changes in local service provision and staffing arrangements. We strongly support this work.
There would be very few occasions (due to adverse weather or other factors) when it will not be possible to transfer a patient using either recognised transfer arrangements or if necessary calling on support from the Ministry of Defence. On occasion in emergency situations it may be appropriate to fly a team from the centre to the remote location.
We recommend re-evaluation of ambulance services, including air transfer, to ensure that they continue to provide the support needed as NHS services are redesigned.
Non-emergency or elective care Alongside the provision of 24/7/52 core services, the following services will be provided in remote and rural hospitals:
- some elective work;
- some outpatient work, along the lines of ambulatory day care work;
- community care services such as those provided at Lochgilphead;
- enhanced chronic care;
- diagnostic procedures.
We recommend that:
the public be fully informed about the sustainability of 24/7/52 emergency services and know what to expect in these situations;
there will be provision for triage and stabilisation; and that
effective and reliable transport geared to support patients during transfer from any remote location is essential.
A service that is compliant with the Working Time Regulations
32. Current interpretation of the European Working Time Directive indicates that:
time spent on-call in hospital is to be counted as working time even when the doctor concerned is resting or sleeping; and
it is implied that compensatory rest must be taken immediately after working time so reducing flexibility for both employers and employees.
In effect this is likely to mean that doctors in training will need to change from working on-call rotas to full-shifts rotas and that NHS services are likely to operate effectively with eight doctors for a full-shift rota although 10 could be more practical to minimise out of hours work. There are also implications for senior doctors who should already comply with the Working Time Regulations and who will require to take a period of compensatory rest at the end of working time.
These have profound effects on service delivery and will drive service re-design:
by concentrating 24-hour acute and emergency care;
to ensure continuity of care; and thus
to assure quality of care.
This will be a particular challenge in Scotland's smaller to medium-sized hospitals where this way of working may not be practicable nor achievable. Reform of both service and training arrangements will be necessary.
A service committed to redesign
33. We believe that, to comply with the Working Time Regulations and with current service models, we will not have sufficient doctors across all grades to provide 24/7/52 care in every locality and unit functioning today. As a result it will be increasingly difficult to deliver service especially for 24/7/52 emergency care. Since there is at present limited prospect of employing more doctors to staff the current service, there will inevitably be increasing difficulties in retaining and recruiting doctors. Even if we could secure the numbers required to meet our current service need, current practice suggests that these would not uncommonly be trainees. That would be wrong. Doctors in training already provide too much care.
34. The low clinical demand in smaller units and in remote areas would be insufficient to develop and refresh clinical competence nor to justify the additional staff required to meet the Working Time Regulations.
35. In many instances, we see service redesign supporting an integrated pattern of care involving several different facilities. Teamwork, new ways of working and changing professional roles: all will play an important role in supporting service redesign. Smaller units may need to work with larger units, and in this respect the principles underpinning Managed Clinical Networks should be adopted. These networks, however, will not be sustainable without specific workforce support designed to meet their needs. Most importantly the principles set out in the NHS Circular HDL(2002)69 22 need to be pursued. Each network must be effectively managed, with clear accountability for the service each provides, and staffed by health professionals competent to work in this way.
36. In larger hospitals it will be possible to deliver services around the clock by focusing most emergency or acute care in one area of the hospital with dedicated staff 23,24. Smaller hospitals pose a more difficult problem and each will need to be considered on an individual basis, with decisions relating to critical mass of staff, facilities and resources being weighed against what services can continue to be provided and sustained safely.
37. Key factors in the redesign of medical services include:
local access to safe and sustainable emergency services, supported, where appropriate, by lift and run arrangements ( see also paragraph 31);
where there is no or only partial emergency services, care may take the form of triage - stabilising patients and then transferring them to a location that can provide the range and depth of skills required for the particular clinical need;
the availability of staff, competent and equipped to deliver a safe outcome and with the capacity to work in teams; and
the size and workload of the service or unit and its geography.
Any redesign must:
Managing change
38. Taking forward a programme of service redesign is a major task: a priority recognised by the Executive. It has required NHS Boards to co-ordinate and lead this task and it is important that, where effective redesign requires arrangements to cross Board boundaries, there must be no barriers for doing so. A national and regional focus for service planning to complement and be linked to that for workforce planning is required.
39. We believe that the constraints set out above in respect of working hours and the provision of 24/7/52 care cannot be fully addressed in many locations and services solely within existing health board areas. We therefore reiterate the recommendation in Future Practice to establish much larger managed health economies for Scotland, and believe that this is essential to provide the infrastructure required to deliver such significant service redesign.
We recommend that: The public: 1. must be fully informed about the sustainability of 24/7/52 emergency services and know what to expect in these situations. The service: 2. must recognise that current means of delivering service will in many cases not be sustainable. Redesign is necessary if the service is to survive, and this can only be achieved by organising Scotland around much larger health economies than are provided by the current health boards. 3. must set out service goals (outcomes for planning the service) - nationally, regionally and locally. These must: be as local as practicable, safe and based around the patient journey; ensure that elective work is carried out where possible at a local level; provide for emergency and acute care in all locations. This will involve, where required, effective partnership with larger more extensively resourced centres and the support of effective and reliable transport geared to sustain patients during transfer; and be integrated linking primary and secondary care.
4. must re-evaluate ambulance services, including air transfer, to ensure that they continue to provide the support needed as NHS services are redesigned. The profession, the public and the service 5. must pursue consensus on what services can be delivered safely and to a high quality in a local setting. |