Business Case Title

Business Case Title: Consultant Anaesthetists – one permanent post and one locum post

circa TOTAL £255k

Clinical Leader / Corporate Dept: Dr Kofi Agyare

Clinical Director: Dr Mike Cooper

Lead Director: Mrs. Sheila Puckett

Lead Manager / Author: Dr Claire Euesden

Funding Year: 08 – 09

1. Rational, Introduction and Strategic Context

The requirement to maximise capacity has led to several important developments in work practice within the anaesthetics department:

·  A requirement to open 8 theatres per day, 5 days per week;

·  Minimal fallow time as consultant surgical vacancies are filled by colleagues within or without their clinical unit;

·  Longer working days based on a three session model;

·  Increased demand in support areas such as radiology;

·  Short term pressure to change patterns of service to meet current issues such as 18 week referral to treatment (RTT) compliance.

These changes, and others, have led to a marked increase in the demand for the Trust-wide corporate service provided by the department of anaesthetics. Alongside the changes in institutional practice, other factors have impacted on the ability of the department to meet these challenges. Amongst these are:

·  Implementation of the 2003 consultant contract;

·  Implementation of the European Working Time Directive compliant rotas;

·  Effect of perceived registrar competence to work under distant supervision and the increased demand that training is provided by direct consultant supervision. This effectively means that training occurs in a fundamentally supernumerary manner;

·  Increased pressure on corporate services such as intensive care requiring extremely high levels on consultant input to provide safe care and maximise safe throughput to facilitate theatre activity.

There has been gradual expansion of consultant numbers. However, there is increasing difficulties fulfilling the service requirement of the Trust. The purpose of recruiting to another consultant anaesthetic post and a locum consultant is to ensure the levels of activity within the hospital are maintained and sustainable service delivery planning for the future is enabled.

Activity within theatres has increased from 8 283 patients in 2004/ 05 to 9 211 in 2007/ 08:

year / total activity
2004/ 05 / 8283
2005/ 06 / 8131
2006/ 07 / 8317
2007/ 08 / 9211

It is anticipated that there will be a similar increase in normal activity into the future for at least the next five years. Indeed, our viability and business case, depends on this. Further, there will be an immediate increase in activity during 2008/ 09 of approximately 5% to meet the 18 week RTT target.

Within the next two years there will also be at least one retirement from the department (one consultant now part time, planning retirement 2009) and succession planning should be considered when developing this service.

2. Current Service Profile

The table shows the current activity demand throughout the week in order to cover all essential areas within the department of anaesthetics:

Monday / Tuesday / Wednesday / Thursday / Friday
Theatres / 8 / 8 / 7 (not inc PPU) / 8 / 7 am & 8 pm
ITU / 1 / 1 / 1 / 1 / 1
Other Areas / SIU (AD) / PT (am) / AP (pm),
rad (AD) / AP (am) / PT (am), PICCS (am)
rad(AD pcm)
Nominal sessions / 20 / 19 / 19 / 19 / 19.5

[SIU = Spinal Injuries Unit, PT = plaster theatre, AP = , rad = GA radiology session in radiology department, AD = all day, pcm = per calendar month).

If a day is counted as two sessions then this is a weekly demand of 99.5 half day sessions. This does not include overruns, additional weekend activity or predictable on call activity. This is the minimum activity to be covered.

Current Anaesthetic Staffing:

Registrars

Currently we are approved for training to receive up to 12 registrars. Our allocation is 8. This is the minimum acceptable to the Royal College of Anaesthetists to run a new deal compliant training rota. However, competence is lower than in previous years due to reduced apprentice training time. Also at any one time:

·  1 pre on call

·  1 post on call

·  1 staffing ITU

·  1 SpR may take 3 weeks annual leave and up to 3 weeks study leave in any one 6 week block. This is 48 person weeks. Therefore 2 are always away on average. In fact a maximum of three may be away.

·  Crucially ‘Modernising Medical Careers’ has lead to a disrupted supply of registrars. In the last 12 months we have never received our agreed complement of junior staff. The local schools of anaesthesia predict this inconsistent supply is likely to continue.

This means the service component of their job is ITU and on call services. We can only predict 2 trainees will be available with lists. Even then their experience and limited hours would only rarely allow them to run an operative list with distant supervision.

As such they can not count towards sustainably staffing the daily sessions.

Associate Specialists and Fellows

There is one permanent Associate Specialist working 5 flexible ‘old contract’ sessions i.e. 2.5 person theatre days.

There is one fellow. This individual may or may not be post CCT. Again only a proportion of lists are suitable for solo cover. The position can not be guaranteed to be filled. Currently it is likely to be popular but as job dynamics shift then such a service orientated position is likely to lie fallow.

The fellow and associate specialist equate to 1.5 full time equivalent consultants.

Consultants

Consultant / wte anaesthesia / Equivalent clinical days
Cernovsky / 1.00 / 3
Chandra / 1.00 / 3
Cooper / 1.00 / 3
Barcroft / 1.00 (1 day at UCLH) / 2
Edge / 1.00 / 3
Fennelly / 1.00 / 3
Fox / 1.00 / 3
Goldhill / 1.00 / 3
Grundy / 1.00 (1 day from UCLH) / 1
Hetreed / 1.00 / 3
Gad El Rab / 0.80 / 2
Ramesh / 1.00 / 3
Agyare / 1.00 / 3
Salim / 1.00 / 3
Sharma / 0.80 / 2
Taylor / 1.00 / 3
Zarnegar / 0.40 / 1
Yau / 1.00 / 3
Seingry / 1.00 / 3
Total / 17.0 wte / 50 clinical days
(100 sessions)

[Dr Barcroft and Grundy equal 1 full time equivalent]

A recent review of individual timetables showed that all individuals fulfil, at least, their clinical commitments. In fact most are contributing extra activity.

Review of the current theatre schedule (attached) demonstrates that on 9/10 notional clinical half day periods we have only the basic requirement. If a correction factor is applied to include non occupancy (study leave, annual leave, sickness) then only on 1/10 notional half days do we have enough staff to provide a consultant delivered service. This review includes the associate specialist but not the fellow.

As described, to run 8 theatres per day, with no increase in pain or radiology cover, requires 100 notional half day sessions.

Applying a correction factor for non occupancy of 20% (less than the 23% used by nursing staff) means we have to effectively staff 120 sessions delivered by consultants, fellows and associate specialists.

For the purposes of this calculation a full time equivalent provides 6 notional half days. This is allowing for the time based nature of the new contract and an allowance for on call activity.

Therefore the minimum number of FTE staff is 20.

In 2003 contractual terms:

·  An all-day list covers a minimum of 10.5 hours including a minimum allowance for pre and post operative visits. Individual lists may be much heavier.

·  We currently use a 1 session allowance for on call and extra duties. This equates to 4 hours.

·  A FTE consultant is paid for 34 hours of direct clinical care. After removal of the 4 hour allowance for on call this equates to 30 hours per week.

·  10 clinical areas per day equates to 50 per week. This is estimated at 50x10.5=525 hours of direct clinical care.

·  Consultants provide 17x30=510

·  Specialist and fellow equate to 1.5=45 hours

·  This equals 555 paid hours of direct clinical care. A reduction for non occupancy (0.2) means we effectively staff 444 hours.

·  Shortfall = 81 clinical hours= 2.7 FTE

In this calculation the department is 2.7 FTE consultants short to run 8 theatres with no expansion in other clinical areas or time of current lists. This is currently being met by two locum anaesthetic consultants and a fellow. By recruiting a permanent consultant and a locum it will provide robust coverage for the service with the flexibility to deliver the required levels of service and develop as necessary. The fellow’s post will become redundant in the short term and good succession planning is in place.

Overview

In an average week, consultant service is required for:

Theatres / 78 sessions
ITU (5 days) / 10 sessions
Other services / 9.5 sessions
Total sessions per week / 97.5 sessions

In order to calculate this into number of consultant wte requires,

Sessions per year (x52) / 5 070 sessions
- bank holidays (8 days, 160 sessions) / 160 sessions
Total session per average year / 4 910 sessions

Consultants work an average of 40 weeks per year (minus annual and study leave)

Sessions per year / 4 910 sessions
41.6 weeks per year / 118 sess/ week
6 DCC per consultant / 19.7 consultants

3. Service Demand and Market Analysis

The future plans of the anaesthetic services are such that, in order to maintain efficiency within the Trust, the theatres are required to be run as fully as possible. At present this is for two sessions per day over five days a week. Up to 5 theatres may be used all day on Saturdays. There are also 3 overruns planned per day.

There is a potential for the service to develop these working practices into 3 sessions per day throughout the week. This would have further man power implications as this activity becomes regular and is incorporated within job plans.

4. Proposed service profile

* These templates are reflective and are subject to negotiation with the ideal candidates. Each post would comprise of 11 programmed activities – 8.5 Direct Clinical Care and 2.5 Supporting Professional Activities.

For example:

Consultant 1 / AM / PM
Monday
Tuesday / Theatres / Theatres
Wednesday
Thursday / Theatres / Theatres
Friday / ITU/Flexible / ITU/Flexible
Consultant 2 / AM / PM
Monday / Theatres / Theatres
Tuesday / ITU/Flexible / ITU/Flexible
Wednesday
Thursday
Friday / Theatres / Theatres

5. Case for change

There has been a steady increase in surgical procedures undertaken at the Royal National Orthopaedic Hospital. The steady, slight increase in the inpatient waiting list has also been maintained for a number of years. There has never been sufficient numbers within the anaesthetic department to sustainably staff every theatre, all day, Monday to Friday.

The increase in theatre time required to deliver the activity has been developed through a piecemeal increase in anaesthetic consultant provision and is currently relying on two locum consultants and a locum registrar.

The service requirements to deliver a sustainable service within the department requires that these roles are substantiated to one extra permanent consultant and an ongoing locum consultant to be reviewed within eighteen months (this replaces the fellow).

These substantive posts will enable greater sustainability of the current service and enable provision of 8 theatres a day over a five day working practice. The increase in substantive services will also facilitate a greater increase in additional work, including evenings and Saturday working; further, the service will be able to investigate the provision of a three session day without incurring additional sessional payments to staff.

The imminent retirement of one of the anaesthetic consultants during 2009 will also be smoothed by the succession planning of recruiting to a permanent consultant and enable the development of new post.

6. Resource & other implications

Financial implications

Post / wte / Cost (£)
Consultant 1 / 1.00 / 120 000
Consultant 2 (locum) / 1.00 / 120 000
Medical Secretary / 0.20 / 5 000
Theatres – MTO
Theatres – Nurse
Theatres – Nurse
Radiographer
OT
Physio
Orthotics
Total Pay / 2.20 / 245 000
Total Non pay / 10 000
Total / 255 000
Registrar locum/fellow / 1.00 / (78 297)
Locum consultant / 1.00 / (92 726)
SHORTFALL / 2.20 / 83 977

7. Service benefits and risks

Benefit to purchasers / patients:

·  Ability to deliver the necessary service required by the Department of Anaesthetics;

·  Ability to meet the NHS Plan waiting time targets;

·  Improved patient satisfaction and access to service;

·  Enhanced recruitment & retention opportunities

·  Succession planning within the department;

·  Enhanced reputation for the Trust as a world class leader in treating patients with complex orthopaedic conditions, to support specialty departments to carry out research and teaching.