Introducing a new Surgical Care Team

Care and staffing models

Healthcare providers should adopt different models for the deployment of extended surgical care team roles based on the needs of their service and its patients. They should try to make best use of these roles’ professional and clinical skillset across the patient pathway while delegating the right level of autonomy and decision-making based on their training and experience.

Surgical care team roles should be developed with the aim of improving patient experience, training and service delivery rather than being introduced to undertake tasks that other clinical staff do not wish to do. The job plans of surgical team members should be developed flexibly to support the delivery of high-quality patient care. This promotes the development of the service by ensuring that all team members have opportunities for high-quality training and learning experiences.

Key factors that should be considered when designing a care model that includes extended surgical care team roles are the following:

• Attention should be given to the whole patient pathway, from outpatient, admission to discharge and follow-up in both the operating and non-operating environment.
• The job plans of extended roles should include a combination of clinical and administrative responsibilities
• Emphasis should be placed on integrating the practice and training of these roles within the wider surgical team, and avoiding lone roles with strictly task-based job plans.
• Experienced practitioners can provide valuable learning opportunities for early-year trainees. SCPs in particular can facilitate controlled withdrawal of supervision with medical trainees in the operating theatre, as it has been recognised that the experienced SCP can act as a skilled surgical assistant. The transition for the junior trainee is from operating with a consultant present to operating with the consultant contactable but not directly in theatre. This should be considered when introducing these roles into the surgical team.
• The introduction of extended roles should be flexible and sensitive to the varying needs of other staff such as trainees, and the training opportunities available to them. In some cases, for example, it might be important that some operating lists are reserved for trainees to ensure sufficient exposure to specific procedures to meet the requirements of the particular stage of their training.
• Extended roles can be embedded within a surgical team, or attached to a specific ward.
       - The team-based system involves surgical care team roles being attached to one or more consultant teams and looking after all the patients in their care, regardless of where they are located in the hospital. Such an approach provides benefits to patients, such as continuity of care. It also offers more opportunities for learning and feedback and fosters closer relationships between the surgical care team member and the wider surgical team.
       - The ward-based system involves surgical care team roles being stationed on particular wards and looking after all the patients on those wards regardless of which consultant is in charge of their care. Such an approach has been shown to have positive implications for patient morbidity and mortality as well as length of stay, and can improve the collaboration between practitioners and nurses. They also provide a steadier workload than the team-based system.

The team-based system involves surgical care team roles being attached to one or more consultant teams and looking after all the patients in their care, regardless of where they are located in the hospital. Such an approach provides benefits to patients, such as continuity of care. It also offers more opportunities for learning and feedback and fosters closer relationships between the surgical care team member and the wider surgical team.

The ward-based system involves surgical care team roles being stationed on particular wards and looking after all the patients on those wards regardless of which consultant is in charge of their care. Such an approach has been shown to have positive implications for patient morbidity and mortality as well as length of stay, and can improve the collaboration between practitioners and nurses. They also provide a steadier workload than the team-based system.

Both approaches have advantages and disadvantages and can be used depending on what those introducing the new model consider will provide the best outcomes for patient care, meet the needs of the service, and support the development of a high-quality training and learning environment. Hybrid models may also be considered.

Rotas

Surgical care team members can provide cover at night and weekends, working with more senior trainees under the supervision of the on-call consultant. Currently, many rotas include gaps and often there are not enough surgeons able to provide generic ‘first on-call’ cover. This means that those in training may work rotas with an excessive number of night duties. Practitioner roles in the surgical care team could contribute to such rotas, allowing early-year surgical trainees to spend more time in daytime care that supports their training.

However, we strongly recommend that no practitioners should work exclusively at night-time or over weekends to avoid isolation and to ensure that surgical trainees also gain sufficient experience of delivering surgical care at these times.

Rotas for the surgical care team can include both elective and emergency work within the scope of their practice, and should be used flexibly to ensure an appropriate balance is achieved between the individual training and development needs of team members (including surgical trainees) while maintaining the best quality patient care. For example, where a surgical trainee is working with a consultant surgeon on an elective care list, a surgical care team member might be used to support emergency activity. A varied and flexible approach should be adopted that is sensitive to the needs of patients, service delivery and training.

Surgical care team members can have their own rotas, providing continuity of care for the patient, supporting rotating trainees, and helping services to meet waiting targets.

Experienced surgical care team members could also be part of a mixed rota with doctors in training, addressing service delivery needs and increasing trainees’ opportunities to attend elective theatre sessions and clinics that are crucial to that stage of their training and development.

Introducing a new model of service

The introduction of surgical care team roles requires a strategic and managed approach to ensure successful and sustainable implementation. An organisation needs to have a clear understanding of how the role contributes to the quality of patient care, and the organisation’s priorities for the development and delivery of services.

The questions below can be used to support the planning, development and introduction of surgical care team roles.

Planning and recruiting

1. Is there a service and workforce requirement for the extended role in the surgical team?
2. What are the benefits of introducing this role to the service, to patient experience and surgical training?
3. Is there sufficient case volume and case mix to ensure that extended roles and trainees have adequate exposure to training opportunities, supervision and assessment?
4. Can the service need identified be addressed through the skills and competencies of existing roles and staff?
5. Will the practitioners be recruited from existing staff and if so, how will the service gap be addressed?
6. Is there support from senior consultant surgeons for the role? Is there managerial agreement?
7. Is there approval from the clinical governance committee?
8. What are the clinical activities that the practitioner will carry out on a day-to-day basis? Is the caseload appropriate for the extended role?
9. Are there arrangements for cover in case of absence, eg sickness absence?
10. Are local policies in alignment with the role and responsibilities of the extended team member?
11. Is there a completed risk assessment to determine the range of procedures that the extended role can perform, and to set an action plan to mitigate risks?
12. Are clear responsibilities detailed in the job description and supported by local policy?
13. How will the salary and costs of training and professional development of this role be funded? Are the costs sustainable?
14. What type of employment contract will the practitioner have?
15. How will other members of staff be informed about the new practitioner?
16. How will patients be informed about the new practitioner?

Training, management and supervision

1. Have you considered the professional, clinical and managerial responsibility and accountability for this role?
2. Do consultant surgeons have capacity, ability and willingness to provide clinical supervision, management and support to the new role?
3. Whom will this role be clinically responsible to and who will be supervising them?
4. Are there induction plans, as well as mentoring and peer support networks, in place?
5. How will the practitioner access theoretical and clinical training and development? Is there access to an appropriate training programme?
6. How will the practitioner’s theoretical knowledge and clinical skills be assessed?
7. Is there a role-specific appraisal framework in the organisation? Who will have the responsibility for undertaking the practitioner’s appraisal, development review and personal development plan?
8. Are there plans in place to support the practitioner’s continuing professional development?
9. Have the minimum qualifications for this role been taken into account?
10. Is there sufficient employer liability insurance for each individual practitioner? What are the limits of this role in line with the organisation’s liability arrangements?
11. How will the effectiveness of this role be audited/evaluated? What are the measures of success?

Risk assessment

1. Is this activity commensurate to the approved scope of practice of the extended team member?
2. Is this activity supported by a job description and departmental policy?
3. What training and education has the extended team member received?
4. Has the extended team member’s competence been assessed appropriately? Are there arrangements for supervision by a senior consultant during the activity when being trained?
5. Is there an adverse impact on the educational opportunities available to surgical trainees?
6. Does the extended team member agree to carry out the activity?

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