On-call rotas work well in private units
Co-operative private practice works for consultants in private practice, drives change for the better and improves the business. Anaesthetist Dr Simon Webster reports on a forward-thinking success story.
The GAS team: Anaesthetists Charles Garcia-Rodriguez, Warren Doherty and Simon Webster
‘Working together is success’. This somewhat selective use of Henry Ford’s quote describes the multitude of benefits to participation in cohesive, collegiate co-operative working by a group of specialists leading to successful private practice.
The concept of co-operative working is not new, but now there appear to be decreasing reasons why individuals would want to continue their activity in the private sector in a siloed fashion.
As hospitals, patients, surgeons and, importantly, regulatory bodies look for reassurance that the risks of patients coming to harm are minimised, a modern and engaged anaesthetic group practice is perfectly aligned to these expectations.
Gloucestershire Anaesthetic Services (GAS) was established in the county by forward-thinking and like-minded individuals in 1987.
Collaborative working
Somewhat uniquely, this involved, at the time, the collaborative working from two NHS hospitals: East Gloucestershire Trust and Gloucestershire Royal Trust. The co-operative working of these anaesthetists pre-dated the formal and harmonious merger of the two trusts in 1995 to form Gloucestershire NHS Trust.
From those few anaesthetists who made up the initial members, GAS has now expanded to 37 individuals who work across two private hospitals, NHS facilities and a local charitable hospital to cover work in up to nine theatres a day.
The complexity of this degree of service is significant, but by a principle of even distribution of work and equal financial benefits with the support of several excellent administration staff, the success of GAS has grown over the decades and especially over recent years.
The last few years have seen, with changing ideas and expectations, the development of high-quality wrap-around care for our patients, benefiting them, our hospitals and colleagues.
We have been extraordinarily lucky to work in two private hospitals, Nuffield Cheltenham and Ramsay Winfield, who have been unflinching in their support both in discussions, time and financial support to help us develop these services.
Weekend on-call rota
One of the most important changes we undertook was to formalise a weekend on-call rota to provide 24/7 anaesthetic cover with a single point of contact from 5pm Friday until 8am Monday for both private hospitals.
To facilitate this, all the GAS members work three weekends a year in a split of ‘A’ and ‘B’ weekends.
When this system was introduced, it was understandable that more senior members of GAS, who hadn’t been on call in the NHS for many years, were anxious about the return to on call. To facilitate this, 26 individuals contributed to two ‘A’ rota on calls (Fri-Mon on call) and one ‘B’ rota shift (daytime list on Saturday) per year.
The remaining senior members undertook three ‘B’ weekend shifts a year. This pattern ensured weekend work was shared but that the whole membership felt supported.
There is no financial charge for these on-call weekends, but they are accepted, as they ensure safe and comprehensive ongoing patient care and, importantly, ensure weekend cover didn’t purely fall to those anaesthetists unfortunate to only work on Thursdays and Fridays.
Since the introduction of the weekend on call, we no longer face challenges in covering Friday and weekend lists and, on several occasions, we have been rapidly able to assess unwell patients.
Pre-operative assessments
The NHS has developed its practice in view of pre-operative assessment over the last decade and this has expanded considerably in the last five to six years.
GAS has been able, with the support of the Nuffield and Winfield hospitals, to mirror this to ensure all high-risk patients are identified early in the operative booking pathway and reviewed in clinic.
Due to the size of the membership, GAS can provide between two and four regular consultant pre-operative assessment clinics weekly, delivered by a cohort of anaesthetists with experience and interest in pre-op assessment.
Related to this service, we have fostered close relationships with colleagues from cardiology and respiratory medicine such that specialty reviews can usually take place within five to seven days of being reviewed in an anaesthetic clinic.
Through our support of pre-operative assessment, we have worked with our hospitals to develop inclusion/exclusion criteria, reduce on-the-day cancellations and work towards patients only being listed for surgery once the pre-operative assessment phase is completed.
Any patients that are not deemed fit for the independent sector are seamlessly anaesthetised by a GAS member in an NHS facility.
The final part of our wrap-around patient care is the provision of peri-operative care, believed to be our only responsibility when I started private practice 12 years ago.
This aspect is the core of our group’s unique selling point: having 37 members all with a differing area of interests, skills, knowledge and clinical experience ensures that we can always cover any surgical specialty list and, due to the resilience in our system, last-minute challenges such as sickness, busy overnight on-calls don’t impact on the delivery of anaesthetic services.
Helping hands
The memberships’ collegiate working extends to the ‘helping hand’ both in a crisis and electively, and the burden of difficult decision-making – an unexpectedly high-risk patient on list and whether to cancel or, in Covid, when only low-risk surgery was permitted – is shared without fear of ‘losing face’, reputation or the greatest fear: losing the list!
Co-operative private practice works for us individually and as co-operative membership. It has undoubtably driven change for the better regarding patient care, surgical support and reassurance for the hospitals.
Together, GAS has been able to work to improve our business both from a financial and quality perspective, but this has also helped our hospital partners build their business in partnership with us.
However, finally, and maybe most importantly, it has maintained a happy and cohesive group of individuals within our NHS department. I, for one, find the reassurance of colleagues who will work with me for the better of all stakeholders truly does prove that ‘working together is success’.
Dr Simon Webster (right) is a consultant in anaesthesia and intensive care and clinical lead for critical care at Gloucestershire Hospitals NHS Foundation Trust