When Lincoln and Louth trust decided to try to become the first in the region to achieve full accreditation under the junior doctors''new deal' (see panel), the changing ground rules in the agreement made the target seem increasingly elusive and, at times, impossible.
Achievement of accreditation - in September last year - had been a key goal of the trust, and the local implementation group had worked for over a year.
Many challenges, such as accommodation, hot food at night, bleep policies and employing nurse practitioners, have been long-standing.But the state of preparedness was often transient, and juniors'views of the new deal relate to perception and memories of the last night on call.The regular turnover ofmedical staff was also problematic.
We decided to undertake dictaphone studies of teams of juniors on call, with a member of the personnel department shadowing a junior doctor one night a week.
This revealed not just the crude data on rest, but a plethora of operational irritants which were often easily resolved and were perceived by the juniors to be of equal value to protected rest.
As a result of our studies we recruited three clinical support workers in July 1999.Similar posts have now been introduced elsewhere in the UK.
These workers undertake tasks such as cannulation, phlebotomy and electrocardiogram (ECG) monitoring, and, more recently, blood culture analysis.They report to the night duty co-ordinator (a nurse) and work to the house officer in medical and surgical specialties.
Two clinical support workers work Monday to Friday from 4pm-midnight, with one on duty from 1pm-6pm on Saturday and 8am-1pm on Sunday.
There was scepticism as to whether we would be able to recruit staff to work the shifts, but we had an excellent field of candidates after an open day.
They receive the same training as a phlebotomist and ECG technician, as well as hospital orientation.None had a clinical, technical or NHS background, but they had interpersonal and communication skills.Their induction included risk management, infection control, resuscitation training, exposure to accident and emergency, and shadowing a nurse and a junior doctor.They are paid£9,000 pro rata, for 365 days a year, at an annual cost of around£27,000.
The clinical support workers have been accepted by nurses and juniors.The doctors speak glowingly of them in their exit interviews and they have made a major contribution to recruiting junior doctors to the trust. It is easy to see why.A junior on call can expect not to be called for routine 'inappropriate' tasks before midnight and not to undertake routine tasks at weekends.They liaise with the clinical support workers, with tests done at their request and results available when they see the patient.
Patients are seen quickly and tests done in one visit.
Our audit showed other benefits: serial ECGS can be done at the weekend; new house officers felt they had emotional support as well as a physical presence, and the suppor t workers were able to assist in informa l train ing of nurses in procedures such as cannulation.Nurses are trained in these tasks, but on busy wards support is not consistent.
The postgraduate dean referred to the influence the innovation had had on the perception of juniors at Lincoln, which we felt was a major factor in achieving accreditation.No funds were available from the taskforce for the clinical support worker posts, but the cost of failing accreditation or paying class-two additional duty hours may be greater. In terms of skill-mix, many trusts have hard-pressed nurses trying to cope with routine technical tasks.
The clinical support worker initiative would not have been possible without the backing of the medical director and director of nursing. It also had to be carried out with junior doctor representatives, who had to be our advocates and have 'ownership' of the project.Turnover rates can make this difficult, but not impossible.
New deal: and the rest Guidance issued in 1998 on the 'new deal'on reducing junior doctors'hours (HSC 1998/240) required a named individual at trust board level to take responsibility for meeting the required standards to ensure accreditation.The circular highlighted the need for local solutions to local problems, encouraging a range of measures such as a review of skill-mix.
Key features of the new deal include ensuring that juniors' rest periods are adequate to ensure safe working, not short periods of rest with frequent interruptions. Payment for additional duty hours can be made where work intensity on a partial shift or on call is greater than should be expected.Trusts are also required to oversee appropriate accommodation arrangements.Ensuring juniors get meal breaks away from wards, with hot food available, is another key consideration.
David Wright is assistant director of personnel, Lincoln and Louth trust, Professor John Walls is postgraduate dean and Kerry Woodford is junior doctor co-ordinator, faculty of medicine and biological sciences, Leicester University.