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In July 2011 the College started a project to study the impact of new ways of working, particularly the resident shift working consultant and other models of consultant delivered care (CDC).

This six-month project began with a survey of all paediatric inpatient and neonatal trusts in the UK to look at the extent to which consultant delivered care models were already being used.

Based on the survey results, we conducted in depth site visits at 10 trusts to look at the impact of these ways of working on team members and resident consultants, as well as a range of indicators.

The College recommended this model of working in Facing the Future (April 2011) as a solution to difficulties in staffing middle grade rotas and undertook this project in July 2011 to provide a firmer evidence base.

Project aims

• Assess the impact of consultant delivered services on:
  • training of junior doctors
  • support for nursing and other health professionals
  • outcomes in children’s health
  • number of admissions, length of stay, and other cost indicators, eg any reduction in locum costs
  • adherence to standards
  • consultants’ work/life balanceÌý
  • development and retention of consultant skills
• Develop models of effective service delivery using RSWCs
• Identify service configurations where the models are most appropriate
• Make recommendations on best practice, and how to implement the changes effectively to members of the RCPCH, the public, NHS workforce planners, educational leads, service commissioners and providers.

Key findings

The following are key findings and recommendations from the Consultant Delivered Care - an evaluation of new ways of working in paediatrics report. The full report and further reading can be downloaded below.

• There was a high compliance with four of the ten Facing the Future standards at the sites visited.
• 96.4% of surveyed units operate some form of consultant delivered care (consultant-led handover, consultant of the week or resident consultant shift working).
• Consultant led handovers happen once a day in 90.3% of the surveyed units.
• Of 53 people interviewed on the site visits, 79.2% believe consultant delivered care is a good service model, with better decision making, reduced admissions, good teaching and on the job training being mentioned in the responses.
• Just under half (48.3%) of the clinical directors interviewed thought their model was sustainable, and 37.9% were unsure.
• The majority of responses from trainees indicated that the model has improved training, although there was concern that it may disempower trainees because consultants make the decisions.
• Senior nurses most frequently mentioned that this way of working led to better team working, better decision making and better communication.
• AmongÌýthe trusts visited, compliance with four Facing the Future standards was between 81.8% and 100%.
• The proportion of vacancies on rotas in the sites we visited is far lower than the national average, 7.6% for Tier 2 compared with 20.4% recorded in the RCPCH national compliance survey conducted in 2010.

Recommendations

1. Outcomes of this project could be applicable to other 24/7 specialties where the use of cross cover to provide the out-of-hours service is not appropriate.
2. Robust and continuous workforce data collection and planning is crucial for achieving the correct balance of trainees and consultants.
3. Short Stay Paediatric Assessment and Observation Units (SSPAOUs) are a cornerstone in the provision of 'care closer to home'. Work needs to be undertaken in conjunction with commissioners and the Department of Health to ensure this form of care is not compromised by perverse financial incentives.
4. Team job planning is essential to determine how best to meet the needs of the service and individuals. Organisations should be supported by a paediatric clinical network so that paediatricians can obtain advice from specialist colleagues and be confident that consistent clinical pathways are developed.
5. The consultant delivered care model should be considered as a means of addressing rota vacancies, reducing locum costs and ensuring EWTR compliance in practice.
6. The application of a consultant delivered service and resident consultant model can be adapted to suit each organisation’s needs and is not a 'one size fits all' solution.
7. Birmingham Children’s Hospital PICU has developed a model which utilises a sliding scale of on-call commitment proportional to the experience of the consultant as a means of reducing the on-call intensity for older consultants. RCPCH believes there is potential for this model to be adapted to fit other service configurations.
8. The RSWC model is central to the achievement of the recommendations in Facing the Future and RCPCH data show that the number of resident shift working consultants is increasing. The RCPCH needs to ensure that medical students and trainees are kept fully informed of the CDC model and the shape of paediatric services in the future.

Further reading

Academy of Medical Royal Colleges (2012). Ìý

Sen et al (2012). Emergency Medicine Journal.

The Academy of Medical Royal Colleges’ January 2012 report.

The Royal College of Paediatrics and Child Health’s May 2011 documentÌýResponse to the Academy of Medical Royal Colleges’ Benefits of Consultant Delivered Healthcare: call for evidence (PDF, 254KB, 5 pages)

The Royal College of Surgeons of England’s 2009 document The consultant surgeon and the consultant-delivered service.