Report For RCPCH
Resident On-call for Consultants in Paediatrics
Background
With increasingly restrictive hours-of-work regulations it is becoming difficult to maintain skilled 24hour paediatric cover. Where there are insufficient doctors in recognised training grades to fill the
rota in an acute unit, alternatives need to be considered. Many units employ non-training grade
doctors for this purpose. However others have chosen to go down the line of consultants acting
down at middle-grade out-of-hours. This has the obvious advantages of continuity and improved
clinical care through having very experienced resident staff.
The situation in Salisbury
Salisbury is a small DGH, with a level 2 NICU and one Children’s Ward with 16 inpatient beds.
There are 2500 deliveries p.a. On average there are 3 or 4 ward admissions out of hours, plus a
similar number of ward attenders. The hospital includes a fully-staffed obstetric department, an
emergency department that takes all-comers, and the regional burns & plastics and cleft lip &
palate services. These all contribute to the out-of-hours workload.
Our next nearest acute paediatric unit (and also our tertiary centre) is Southampton, at least 45
minutes away by road.
The consultant resident on-call scheme started in August 2004, initially with 5, then 6 and since
2010 with 10 consultants participating. Initially we had only 3 middle grade doctors (1 Registrar, 2
Senior SHOs) and we now have 4 (1 extra Registrar), although one of these posts is often unfilled.
It would be difficult to justify the eight training-grade doctors that would be needed to run an hourscompliant rota in such a small unit.
Numbers needed to participate
We initially estimated that we needed 6 full time consultants to make the system effective without
an appreciable diminution in day-time consultant availability. The system started when a 6 th
consultant was appointed. However, it became apparent after a year or two that the day time off
was having a significant detrimental effect on our ability to meet out-patient waiting times targets,
and we were getting inadequate time for all the required supporting activities: clinical governance,
service development, teaching and assessment, etc. In addition, the enforcement of the 48-hour
working week for trainees meant that we had to reduce the middle-grades hours further. All this led
to a Trust decision to employ 4 further consultants. We now have 8 full-time (10.5 PA) and two
part-time (8 PA) consultants, all of whom do resident on-call.
Working Pattern
Effectively the out-of-hours cover is divided roughly equally between the middle-grades and the
consultants.
To comply with regulations the middle-grade doctors may not work any longer than an 13 hour
shift.
Consultants therefore have to fit in with this shift pattern. At nights and weekends
consultants therefore effectively work a 13 hour shift.
The middle-grades are required to have a day off before and after a shift, although consultants
usually work a normal working day before a weekday night shift, with a 4 hour break between 5
and 9 pm.
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The most valuable day-time training opportunities for middle-grades occur Tues-Thurs. In order to
allow middle-grades sufficient access to these, most of the mid-week nights are done by
consultants. Weekends are shared equally.
In practice, a day off is always taken after a resident night on call, and on certain other scheduled
days. We are able to organise our clinic activities so that they are never scheduled following a
resident night.
When a consultant is working a resident shift, there is always a 3rd on backup consultant available
from home, for the unusual occasions where 2 skilled people are needed at once. This happens
not infrequently on weekend days, particularly when SHOs are new, but it is rare to be called at
night when a consultant colleague is resident.
The rota is of necessity quite complex. In practice, each consultant works about 1 resident
weekday night per fortnight, and 2 sets of weekend shifts (either days or nights, Friday, Saturday
and Sunday) every 20 weeks. When added to our normal on-call from home commitment, this
equates to working at least part of 1 in every 5 weekends.
Levels of activity when resident
Most ward admissions are seen before midnight. The work-load for the resident consultant is
therefore on the majority of nights not too arduous between about 1 am and 7am. It is unusual not
to get at least a few hours sleep, albeit interrupted.
Resident on-call is always with an SHO, but they may be quite junior. The level of activity is clearly
busier every 6 months when the SHOs are new.
Clinical care and training
Children admitted out-of-hours undoubtedly benefit from receiving an immediate senior
assessment, and this probably results in fewer unnecessary admissions. Unfortunately this is
impossible to demonstrate numerically in the face of the general trend towards increasing
admissions.
SHOs (and nurses) find the quality of their out-of-hours training enhanced by a senior presence on
the ward.
Effect on day time service
With adequate numbers of consultants, we found that starting to do resident on-call has not
significantly increased outpatient waiting times. There are still roughly the same number of
children passing through the outpatient department as before the scheme started.
Time available for consultants for non-clinical activity during the day has diminished. In practice
we find ourselves frequently doing admin, management and teaching tasks out of hours during our
resident shifts.
There is a ‘consultant of the week’ scheme for day-to-day continuity on the ward. The consultant
of the week does not do any resident on-call that week, so they are always available during the
day.
Consultant Contract
Resident on-call is worked strictly according to the 2003 Consultant Contract terms. All time spent
as resident counts as time worked. Time spent as resident is between 7pm and 7am, and all day
at weekends, is premium time (3 hours = 1 PA).
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The arrangement is voluntary and subject to review.
Accommodation
Initially our sleeping accommodation was sub-standard but after prolonged negotiation with the
Trust, we now have a very acceptable on-call flat, which is a reasonable distance from the acute
areas and very comfortable. There is an ensuite bathroom and our own kitchen and sitting room.
Affect on work-life balance
We all appreciate having one or two week days off per week in compensation for doing the
resident on call. After a busy night, some of this may be spent sleeping, but at other times we use
it for pursuing other activities, either work-related or not. Consultants with young children
appreciate the extra time they are able to spend with their families.
Management issues
Once the National Contract was negotiated, we had no difficulty in negotiating with our own Trust
acceptable conditions for doing resident on call. The Trust management are very committed to
maintaining 24-hour skilled paediatric cover in Salisbury. This service is seen as necessary to
support the ‘flagship’ burns, plastics and cleft service in our Trust. Reconfiguring the acute
paediatric service would be geographically and politically unacceptable, and at present there are
no plans to do this.
Recruitment
Seven new consultant appointments have been made since we decided to operate in this way. It
is notable that two of the successful appointees had worked in a similar scheme as locum
consultants in Dorchester, and three others had seen it in action while working as registrars. They
were not put off applying because of this.
We have no way of knowing how many potential applicants who might have otherwise been
interested were discouraged by the requirement to do resident on call.
Situation in other Units
In Dorchester and Basingstoke, a similar scheme started before us in Salisbury. Each of these
units has a different rota system and different arrangements for remuneration and time off. I
believe there are units in other parts of the country doing something similar but I have no
information about this.
(Contacts: Dorchester – Dr Phil Wyllie; Basingstoke – Dr Priya Ilangovan)
Conclusion
In spite of many people’s reservations, consultant residence on-call has worked successfully. This
is largely due to the commitment of the consultants and local management. The implications for
consultants’ life-style, and for sustaining the daytime service, have not been as adverse as
expected.
Reference: Scott-Jupp R. Consultants sleeping-in. BMJ Career Focus 2005;330:145-146
Dr Robert Scott-Jupp
Consultant Paediatrician
Salisbury District Hospital
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