Pilot reduces doctor overtime and improves efficiency.
Developing staff as Doctors' Assistants from HealthCare Assistants in
acute National Health Service (NHS) hospitals is
safe, efficient, high value and improves patient
There is a crisis in the UK NHS, with reductions in doctors’ working hours and a relentless increase in numbers and complexity of patients (HEE, 2017). Other reports catalogue that doctors in training posts spend half their time on administrative work (RCS, 2016), dominated by repetitive and menial tasks (Morrow, 2012), with 99 percent in posts which fail standards for educational opportunities (ASiT/BOTA, 2017), morale is low (GMC,
2016) and there are excessive vacant posts - an average of 9.6 percent vacancies in hospital doctor posts (HEE, 2017).
The workforce challenges, including vacancies of doctors, mean lengthy waiting times for patients in busy acute hospitals for essential tests, treatments or discharge paperwork, across seven-day services.
In the UK NHS, most staff are on pay bands of ‘Agenda for Change’; Band 5 is typically for a staff nurse on qualification or similar degree-level staff who often have Registration with a national body; Bands 6, 7, 8a and 8b signify progressively more autonomous clinical or managerial roles with additional training, expertise and salary (NHS employers, 2017). There are many good initiatives to develop Registered autonomous staff into Practitioner level (Band 6, 7 or 8a) (HEE, 2017). Developing practitioners can be perceived as expensive and competing with doctors for training and complex tasks (Matthews, 2017) not always fulfilling the local need (Bruce et al, 2016) and depleting other staff groups. Even Band 4 roles have been criticised for excess autonomy (Bodkin, 2016). Conversely, there are very few NHS clinical roles at Band 3, an Assistant role, with minimal autonomy and no requirement for registration. The Carter review (2016) and NAO (2017) recommend sustainable development of local staff, which our development of Band 2 into Band 3 staff aims to deliver.
We report a project developing a new NHS role of Doctors’ Assistant at Band 3 (£18,000 mid-point + on-costs) and its progress through planning, successful six-month pilot, evaluation, business case development and dissemination.
We undertook a six-month pilot of appointing/developing six Doctors’ Assistants at pay Band 3 from our existing Healthcare Assistants, initially through a process of secondment. Initial work with a wider group of clinicians, the education team and managers identified key delegable tasks traditionally done by ward/training/on-call doctors (cannulation, dementia screening, drafting discharge summaries, venepuncture, writing in notes, finding test results and taking requests) and devised a two-week induction course. We created robust processes, including recruitment process, pre-reading dossier, two-week induction, communication strategy, rotas, uniform and weekly tutorials. We worked across departments (initially Clinical Education, Finance, IT, Medicine, Surgery and Cardiology; later rolled out to Orthopaedics and Urology). We acknowledge learning from other pioneers (Brighton and Southampton) (Kause, 2016).
NHS Health Research Authority approval/ethics (ref 215636: REC ref17/HRS/0019) was obtained through Proportionate Review. This was an Action Research project. Quantitative data included recordings of times and activities of doctors at baseline. Similar data were collected pro-actively from Doctors’ Assistants time sheets. Routinely collected Trust data were scrutinised. Feedback was sought from staff. Qualitative data were analysed thematically.
We prioritised communication with stakeholders including hospital staff, GPS and patients. Fears over ‘dumbing down’ were ameliorated with our ‘no-involvement-with-medication’ rule. We listened and responded to feedback (eg business cards listing tasks/bleeps, targeting teaching, checklists, ward round trolleys, etc). We had articles in internal and local press and attended team and individual meetings.
At baseline, doctors’ logs showed 44 percent time doing admin. 78 perent of exception reports (overtime from junior doctor contract) were for tasks that could be delegated. Doctors reported 88 percent greater likelihood of attending teaching/operating sessions if a Doctors’ Assistant was present.
Qualitative assessments demonstrated pride, support and very positive feedback from all grades of staff. Three themes identified as vital for success were: supportive line management, communication with stakeholders and defining role boundaries (eg no contact with medication to reduce perceived risk).
The Doctors’ Assistants were especially useful at evenings, weekends and Bank Holidays, when there are fewer doctors, with multiple instances of improved care or improved patient flow. For elective wards 8am-6pm Monday-saturday worked better than long shifts.
Our new curriculum was very clear on the skills expected and the level of knowledge and attitudes required. We also involved the Doctors’ assistants in other initiatives: this included additional workshops on ‘Making Every Contact Count’ so they were empowered to discuss general health with patients; induction included sessions on Behaviours, to identify behaviour that could be perceived as bullying and to have a way of dealing with this. These aspects of culture change merit development.