doctors’ assistants

Doctors’ Assistants -a new NHS hybrid admin/clinical role

Mrs Scarlett McNallyBSc FRCS(Tr&Orth) MA MBA FAcadMEd

Consultant Orthopaedic surgeon

For RCS Extended Surgical Team conference 24.3.17

Resources on last page…

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I have no conflict of interest:

• I am an elected Council member of Royal College of Surgeons of England

Any Member of Fellow can

stand!Please apply inJanuary to be

voted in.6 meetings a

year.

We are more diverse now!

• Two acute hospitals

• 500 beds each

• 45 minutes travel

• Elderly population

• 40-60 medical patients per site daily

Eastbourne DGH + Conquest hospital, Hastings

Problems: Workload & Patient flow• Workload:

• ‘rota gaps’ & vacancies for ward/on-call/training doctors.

• Affecting Doctors:• over-stretched, relentless work with few breaks.

• Training suffering

• Affecting Patients:• waiting to be clerked, waiting for discharge summaries,

causing delays/cancellations for other patients.

• Affecting Trust:• Documentation sub-optimal, so excess ‘mortality over

expected’, coding/communication issues and complaints.

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What if?

• We acknowledged how much time doctors spend on multiple simple tasks?

• We can identify tasks that do not need a doctor to do them?

Southampton – Admin assistant to Acute Medical Unit

Brighton – Clinical/admin on Surgical Assessment unit

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The new Doctors’ Assistants (x6)

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Doctors’ Assistant Physician Associate

Pay BandAgenda for Change Band 3 Band 6/7/8a

Mid-point salary p.a. £18,000 £35,000+

Training Two-week induction Two years

Experience HealthCare AssistantBio-medical degree /

experience

Work Directed Autonomous

HoursWeekends / evenings preferred (+30% pay)

As agreed

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Stakeholder engagement

• Medicine

• Surgery

• Trust Executive

• Nursing

• Doctors in training

• Education

• HR

• Finance

• GPs

• Patients

• Public

• Across TWO acute sites

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What we did:1. Stakeholder engagement

2. Bid for funds: £80,000 from HEE-KSS

3. Recruitment: Job Description, Selection, Rota, Support, six-month secondments

4. Communication & Branding (Bright green)

5. Training• Two-week Induction

• Weekly education sessions

• Feedback

• Support

6. Research / evaluation

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Before they all started:• All had previous experience as HCA

• Contract for six-month secondment

• I.T. test as part of selection process

• Some had NVQ level 2/3 in Health & Social Care

Pre-reading:

• List of common medical abbreviations

• Doctors’ Clinical Handbook

• ‘Learning in operating theatres’

• Avoiding unconscious bias

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CurriculumKnowledge

Classroom (two-weeks):

• Common emergencies

• Coding

• Documentation

• Integrated Care Pathways

• How doctors work/think

• Trust values

Locality-based:

• Shadowing ward/ on-call Drs

• Radiology investigations –processing requests

• Tour of both acute sites

• Meeting other staff

Skills

• IT training – how to get results, order tests

• Admin: notes / discharges

• Phlebotomy

• i.v. cannulation

• Test of abbreviations

• ‘Making Every Contact Count’

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Holistic care -Respect for others & self

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My favourite stuff!

www.rcseng.ac.uk/study

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Research evaluationwith help from University of Brighton

Quantitative:

• Doctors:• Activities

• Diary cards

• Happiness scores

• Doctors’ Assistants:• Activities’ monitoring

Qualitative:• Feedback

• Focus groups

Trust data15

Research websitehttp://www.bit.do/dr-assistants

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“In this study, we want to

evaluate the effectiveness

of the new Doctors'

Assistants role and of their

training process”

“We hypothesize that a

proportion of junior doctors’

work can be completed

safely and effectively by a

Doctors’ Assistant”

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Data collection

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Doctors’ time

Admin36%

Discharge summaries

8%Handover4%

Ward round19%

Patient interaction

31%

Educational session 2%

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Doctors:Time to complete ONE discharge summary: Mean = 19.5minutes

0

1

2

3

4

5

6

7

0 - 5 5.5 - 10 10.5 - 15 15.5 - 20 20.5 - 25 25.5 +

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A Doctors’ Assistant’s typical day

07:30 – 8.30am Help night doctor. Locate patients. Update results. Prep ward round

08:30-10am Ward round. Find results. Write. Jobs.

After round Requests to radiology

10am-4pm Jobs: Discharge letters, cannulae, bloods

4pm-7.30pm Assist on-call teams

7.30pm-8.10pm Prepare for handover to night doctors

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Doctors’ Assistants: Analysis of 50 shifts…Eastbourne -

MEDICALHastings -SURGICAL

Ward Round (incl. results, scribing, jobs)

2.4 hours 1.3 hours

Forms/ patient info 10 mins 70 mins

Prep handover / notes 34 mins 91 mins

Venepuncture 9.0 5.6

Cannulation 4.2 2.9

Requests to radiology/scan 2.4 4.2

Path samples 8.3 4

Discharge summary draft 4.6 6.5

Dementia screen 3.2 3.4

VTE screen 2.9 4.2

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Mean numbers of tasks per shift per Doctors’ Assistant

0

2

4

6

8

10

12

14

16

Mon Tues Wed Thurs Fri Sat Sun

venepuncture (no.) Discharge summaries

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Qualitative:• Doctors’ Assistant: “I did 35 blood tests on

new admissions on one Saturday. If we weren’t there, the doctors would have to do all this”

• Doctors’ Assistant: “there were no beds and the matron said please can you do these 5 discharges so we can help the patient flow”

• FY1: “They free up time from many ward jobs that may take me up to an hour when alone.”

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Qualitative feedback:• FY1: “I don’t know how I’d have managed that day

without her”

• Education Local Faculty Group: “Feedback from

trainee reps regarding the Doctors’ Assistants was

excellent. They would like more of them particularly

on weekends and to help throughout hospital.”

• Medical/geriatric Consultants: “they are just what

we need”, “could one help my ward round now?”.

• Surgical ward sister “let’s get more, to help

discharges and free beds for new admissions”

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Negative feedback- getting others on board:1. Ward sister: “I don’t know why you are here, you

can’t do anything”. Solved - filing weekend notes.

2. Dementia practitioner: Re communication asking screening questions – training session arranged

3. GP: RE early discharge letter – used for teaching

4. New Deputy head of Nursing- querying role -Discussion on Job Description.

5. RE FY1 doctors not knowing how to delegate tasks – we now attend their induction

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Communication

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Literature

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Challenges:1. Line Management:

• for the future, by the administrator who runs the ‘SHO/FY1’ rota

• CLINICAL supervision by senior SAS/ST3+/Cons

2. Communication

3. Support

4. Practicalities:• IT•Rota design 29

37.5 hours/week = One most daysDA1 DA2 = Debbie DA3 = Sandy

Week 1 Mon 7.30am-8.10pm 7.30am-10.30amWeek 1 Tues 7.30am-8.10pmWeek 1 Wed 1pm-5pm STUDY 7.30am-8.10pm* 1pm-5pm STUDYWeek 1 Thurs 7.30am-8.10pmWeek 1 Fri 7.30am-8.10pm 7.30am-8.10pmWeek 1 Sat 7.30am-8.10pmWeek 1 Sun 7.30am-8.10pm

Week 2 Mon 7.30am-10.30am 7.30am-8.10pmWeek 2 Tues 7.30am-8.10pmWeek 2 Wed 1pm-5pm STUDY 1pm-5pm STUDY 7.30am-8.10pm*Week 2 Thurs 7.30am-8.10pmWeek 2 Fri 7.30am-8.10pm 7.30am-8.10pmWeek 2 Sat 7.30am-8.10pmWeek 2 Sun 7.30am-8.10pm

Week 3 Mon 7.30am-8.10pm 7.30am-10.30amWeek 3 Tues 7.30am-8.10pmWeek 3 Wed 7.30am-8.10pm* 1pm-5pm STUDY 1pm-5pm STUDYWeek 3 Thurs 7.30am-8.10pmWeek 3 Fri 7.30am-8.10pm 7.30am-8.10pmWeek 3 Sat 7.30am-8.10pmWeek 3 Sun 7.30am-8.10pm 30

Total project costs:Costs: TOTALS

6 staff at Band 3 £19,000 pa for six months £9,500 each x6 £57,000

Enhancement for weekends 30% x 50 weekend days £1,638

Enhancement for Bank holidays 60% x 5 £327

On-costs (23%) £13,562

Travel £1,000

Polo shirts embroidered (3 each x6) £8 x18 £144

Lanyards £120

Laptops (x2) including software £1000 x 2 £2,000

Messenger bags £8 x6 £48

Bleeps (central funding) £0 x2

Training costs (not costed – 2 weeks) £0

Recruitment costs (not costed) £0

TOTAL £75,839

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Exception reports:

• 78% “workload”/”staffing”/jobs/ “discharge summaries”

• For each hour:£24 / £32 to Doctor (basic/enhanced)

+ £40 / £53 in Fines if over total hours

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Conquest Medicine F1

were 3 on the ward with 28 patients; as staff sick on macdonalds ward; our locum SHO sent there to help out. As a result only two people at the ward to complete urgent jobs.

Conquest Medicine F1 SHO went to cover a night gap and was alone on ward with locum SHO

Conquest Medicine F1

discharges over weekend and needed to be completed so that the patients dont lose their care home beds

Conquest Medicine F1 alone on wards reg sick f2 on call. look after all patients by myself. very busy oncall

Conquest Medicine F1 wards very busy stayed behind late to complete ward jobs and look after sick patients on our wards

Conquest Medicine F1

stayed behind late to complete discharge summaries as bed was needed and patient wanted to go home team still short on junior doctor

Conquest Medicine F1 Heavy workload and 3 patients waiting to be seen as well as ward jobs.

Conquest Medicine F1

ward very hectic; stayed late to complete discharge summaries for the following morning to ensure better flow of beds in the ward

Conquest Medicine F1

Short staffed team with a number of outlier patients. Finished at 7:30 to do urgent jobs. Discharge summaries were not done in time.

Conquest Medicine F1

Started work early to do outstanding jobs including discharge summaries and death certificates from day before. Once again; short staffed. Stayed late to do urgent jobs.

Conquest Medicine F2 In early for ward round at 0830.Finished at 1800 due to volume of work

WHAT NOW?• Business case

• Exception reports

• Keeping people who have got the skill

• Recruiting others

• Creating an Apprenticeship

• Package for other sites:

• Job Description

• Time line

• Induction plan

• KEY ISSUES:

• Line Management

• Communication 33

Model for acute NHS?

We visited Brighton

We spoke to: Southampton

Asked us Torbay

Asked us Sunderland

Asked us Newham

Asked us East Midlands

Asked us Maidstone

Asked for details Royal College of Surgeons of England

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• Why Health Care Support Workers?

• Communication is the key

• New role development - others understanding

• Relevant training, skills and competencies

• Line Management arrangements are important to guide and support - leadership

• Integrated working, partnership working together to make a better experience for Patients and Doctors

• High job satisfaction for Doctors’ Assistants

• NHS Constitution

Head of Clinical Education

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Agenda for change Pay BandsBand 1 £15,251 – 15,516

Add 23%

on-costs

(cost of

employ-

ing,

pension,

Nat

Ins…)

Band 2 £15,251 – 17,978 HealthCare Assistant

Band 3 £16,800 – 19,655 Doctors’ Assistant

Band 4 £19,217 – 22,458Nurse Associate

Pharmacy Technician

Band 5 £21,909 – 28,462 Newly qualified Staff Nurse

Band 6 £26,302 – 35,225Pharmacy Prescribing Practitioner

Orthopaedic Practitioners (OPs)

Band 7 £31,383 – 41,373 Extended Scope Practitioners (ESPs)

Surgical Care Practitioners (SCPs)

Physician Associates (PAs)8a £40,028 – 48,034

8b £46,625 – 57,640

8c £56,104 – 64,484

8d £66,582 – 82,434

Band 9 £78,629 – 99,437

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The financial imperativeApprox 23%

Per week

Band 3 Doctors Assistant £18,000 pa + on costs 37.5 hours

Band 7 Practitioner £40,000 pa + on costs 37.5 hours

Mid-point SHO

Core trainee £49,000 pa + on costs 48 hours

Doctor not in training

Specialty Doctor Pre-Threshold 1

mid-point without overtime

£45,000 pa + on costs 40 hours

Agency Locum More As needed

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March 2017

• Shortlisted for BMJ award ‘Clinical Leadership’

• Poster at RCS Surgical Education day

• Workshop at Academy of Medical Educators 21.3.17

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Lady Estelle Wolfson Emerging leaders

Applicants wanted NOW!!

Tap someone on the shoulder

www.rcseng.ac.uk/study

Please use this!

ANYONE who works in theatre –to help students

and new staff

SET the RULES:

so ALL operating theatre staff help students / trainees

www.rcseng.ac.uk/study

https://www.rcseng.ac.uk/-/media/files/rcs/careers-in-surgery/learning-in-operating-theatres-2016-v3.pdf?la=en

www.rcseng.ac.uk look in

“careers” section

JUST KNOW – there is a way

Supporting students and all doctors

1. Resources

• Undergrad curriculum – re-dissected

• Learning in the operating theatre

• Mentoring guide

2. Structures

• Future surgeons’ forum

• Regional teams (you!) please!

3. Being nice!

• Everybody’s job

• Avoiding unconscious bias

Mentoring: New RCS guide

www.rcseng.ac.uk “publications”

This is a simple guide about being a

mentor or mentee, basic ground rules

National Undergraduate Curriculum in Surgery

CONTENTS:

• What is it?

• Why do we need it?

• How we wrote it

• Curriculum Contents

• Syllabus – key skills

• Syllabus – key conditions

• How to use it

• Syllabus

• Curriculum

• Supporting More Future Surgeons

• Next Steps www.rcseng.ac.uk/study

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Curriculum Contents = 3 sections:

Knowledge (syllabus) + Skills + attitudes/ ways of learning

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Supporting More Future Surgeons

• There are documents to support training:

• Mentoring (support outside any training programme)

• Avoiding unconscious bias (how to treat people better)

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Future surgeons:

- Be nice- Get medical students and Foundation Drs:

scrubbedto join RCS AFFILIATES!!! £15/yearto join Women in Surgery FREE

- Define the tasks- Knowledge is power- OR…

www.rcseng.ac.uk/study

www.rcseng.ac.uk/career

Summary

• Doctors’ Assistants• Band 3 Health Care Support Workers

• Previously HealthCare Assistants

• Needs wide stakeholder buy-in for vision & detail

• Clarity:• Tasks

• Communication

• Line management

• Model for acute NHS?

• Value everybody & BE NICE!

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www.rcseng.ac.uk/studywww.aomrc.ac.uk “Exercise”

scarlett.mcnally@nhs.nethttp://www.bit.do/dr-assistants

http://www.bit.do/dr-assistants• This website contains:

• Job Description

• Person Specification

• Rota ideas

• Implementation tips for different sites.

• Please let me know if you use it! Scarlett.mcnally@nhs.net

• Please use it with care:• People moving from a Band 2 ward-based role need a lot

of support:• Line management by the administrator who runs “SHO” rota

• Clinical supervision by a senior Doctor

• KEEP within the medical team. (Less risk averse than nursing)

• Be clear about tasks and limits.57