Guidance to help manage winter pressures

As we enter another winter, pressure on hospital beds with risks of cancelling planned activities will affect many of us. Congested hospitals, long waits in Accident and Emergency Departments and delays in delivering planned treatments threaten patient safety. Available hospital bed capacity remains limited, finding community and social care places is challenging and the next generation of consultants, particularly those in the craft specialties are experiencing significant difficulties in obtaining their training as elective work is cancelled.

Despite these difficulties, it is important to maintain patient safety by recognising the needs of patients with urgent and elective problems, by ensuring doctors with the most appropriate skills are available to care for patients and appropriately supervised, and that training continues.

Following representations from the Royal College of Surgeons of England, the NHS in England has decided against issuing central guidance to trusts to cancel elective surgery in advance. It remains unclear what decision will be taken in Wales and Northern Ireland. We expect that most trusts will already have made plans to cope with periods of increased pressure that reflect their local circumstances. It is better for patients to be told in advance rather than on the day that their surgery is being cancelled. Nevertheless, the consequences of any cancellation are inevitable; including further delays with prolonged suffering and further restrictions on the ability of trainees to meet their curricula criteria.

We remain in dialogue with government on these points, and the RCS is represented on the National Escalation Pressures Panel which advises the whole NHS on elective and emergency preparedness. The RCS will push even harder for the full resumption of elective surgery post-winter and there must be a detailed plan of how this will take place by early 2019 at the latest.

This guidance, agreed with Health Education England, is designed to assist service providers and doctors to plan for periods of increased activity. It is divided into sections applicable to different grades of doctor and provide some consistency across the country so doctors and managers know what to fairly expect. We stress that this guidance should only apply during defined periods of increased activity where elective operations are severely impacted. We would not support trusts using this guidance outside of these circumstances. While we appreciate there will be a particular impact on surgeons in training, this guidance is designed to help protect, not hinder, training opportunities.

1. Consultants

• Consultants must be involved in and understand the arrangements in place to manage winter pressures within their own hospitals.
• Those working in specialties receiving assistance from trainees in other specialties must provide close tailored clinical supervision, support and training to those trainees.
• Those whose trainees are providing assistance to other specialties must ensure that the skills of these trainees are adequate to provide such assistance and that they undertake duties according to agreed timetables, in order to maintain patient safety.
• Arrangements that affect trainees should be for defined periods with an agreed timetable for their review.
• Assigned Educational Supervisors responsible for core and foundation trainees providing assistance to other specialties must balance the needs of trainees within their own specialty with the needs of patients under the care of specialties under pressure. They must create timetables in agreement with trainees that ensure balance between these requirements.

2. Foundation Trainees

Foundation trainees working in specialties with a significant elective workload (e.g. surgical specialties) might be asked to spend a defined period of time working in another acute specialty (e.g. acute medicine) that is experiencing a significantly increased workload. This should take place under the following conditions:

a) The acute post is in the same hospital as their current placement.
b) The trainee has already worked in the same unit that is requiring assistance.
c) Clinical supervision in the workplace is clearly defined.
d) The trainee receives continued training both clinically and in the Generic Professional Capabilities.
e) This should only be for two weeks and any extension beyond that for a further exceptional 2 weeks must be agreed by the postgraduate dean accompanied by a trust action plan indicating how a further request will be avoided that winter.

3. Core Trainees

Core trainees working in specialties with a significant elective workload that is compromised due to winter pressures (e.g. surgical specialties) might be asked to provide care for patients under the care of other acute surgical specialties experiencing an increased workload. This could take place under the following conditions:

a) The patients under the care of the other acute specialty are on the trainees’ base wards.
b) Appropriate clinical supervision in the workplace is provided by the other acute specialty recognising that trainees will not be able to provide care at an equivalent level to trainees of similar seniority in the other acute specialty.
c) The trainees receive clinical training from the clinical supervisor in the other acute specialty.
d) The training needs of the trainee are addressed by their Assigned Educational Supervisor determining the correct balance between attending training opportunities in her/his own specialty and providing care for patients in the other acute specialty. The trainee must not be expected to provide care for patients in the other acute specialty at the same time as attending training opportunities in her/his own specialty.
e) The timetable which balances training needs with the provision of care to patients in the other acute specialty is made well known to ward staff, the clinical workplace supervisor in the other acute specialty and the trainee’s own Clinical Supervisor.
f) Trainees should only work in areas where they feel competent to provide reasonable care.

4. Specialty Trainees

Specialty trainees whose roles involve a significant elective workload (e.g. surgical specialties) might be asked to provide care for patients presenting as emergencies with conditions cared for within the trainee’s own specialty to ensure that an efficient service can be maintained and that delays in clinical management avoided. This should take place under the following conditions:

a) This remains within the trainee’s normal working hours.
b) This does not prevent attendance at scheduled training opportunities.
c) Clinical workplace supervision is maintained under the normal arrangements for the trainee.

5. Hospital Management

Senior clinical and non-clinical managers in hospitals employing measures described in this guidance must discuss the need for these actions with the Medical Director and Director of Medical Education.

Principles applicable to all circumstances

a) Clinical supervision in the workplace must be clear and agreed to by all parties and must recognise the lower levels of experience and expertise that trainees will have when working outside their normal specialty.
b) Senior clinical management within the service provider (Medical Director, Clinical Director) must agree to the arrangements.
c) Trainees participating in such care must receive due recognition for their work in a form that can be included in their portfolios.
d) Senior hospital management should explain the need for these arrangements to the trainee and consultants concerned.
e) Arrangements must be agreed with the Local Postgraduate Dean.

We appreciate that much is already being asked of our NHS workforce. Our further support this winter will help patients to be cared for safely, protect hospital capacity and training opportunities, and demonstrate surgeons’ continuing commitment to lead by example. It is now over to the government and NHS England to do their bit as they prepare to publish the Social Care Green Paper, the Workforce Strategy, and the 10-Year NHS Plan.