doctors’ assistants
TRANSCRIPT
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…
1
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.
5
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
6
The new Doctors’ Assistants (x6)
7
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
8
Stakeholder engagement
• Medicine
• Surgery
• Trust Executive
• Nursing
• Doctors in training
• Education
• HR
• Finance
• GPs
• Patients
• Public
• Across TWO acute sites
9
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
10
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
11
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’
12
Holistic care -Respect for others & self
13
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
16
“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”
17
Data collection
18
Doctors’ time
Admin36%
Discharge summaries
8%Handover4%
Ward round19%
Patient interaction
31%
Educational session 2%
19
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 +
20
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
21
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
22
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
23
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.”
24
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”
25
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
26
Communication
27
Literature
28
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
31
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
32
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
34
35
• 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
36
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
37
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
38
March 2017
• Shortlisted for BMJ award ‘Clinical Leadership’
• Poster at RCS Surgical Education day
• Workshop at Academy of Medical Educators 21.3.17
39
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
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
51
Curriculum Contents = 3 sections:
Knowledge (syllabus) + Skills + attitudes/ ways of learning
52
Supporting More Future Surgeons
• There are documents to support training:
• Mentoring (support outside any training programme)
• Avoiding unconscious bias (how to treat people better)
53
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!
56
www.rcseng.ac.uk/studywww.aomrc.ac.uk “Exercise”
[email protected]://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! [email protected]
• 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