ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS

IN RESPIRATORY CARE


On-Call Position Statement and Recommendations for On-Call Service Provision

April 2017

First published in 2017

By the Association of Chartered Physiotherapists in Respiratory Care

Date for review: 2020

Procedure for reviewing the document: The ACPRC Committee will take on an initial review of the document to determine whether an update is required. Members will then be informed of this review at the AGM in 2020 for comment. Any member can submit their feedback on the document at any time by emailing:

Reference this document as:

This document is available from the ACPRCs' website:

Acknowledgements

We would like to acknowledge that this paper has been written on behalf of the ACPRC by the members of the on-call working group which comprises:

Sian Goddard

Lizzie Grillo

EmaSwingwood

With support of the 2017 ACPRC Committee

A special thank you to those attendees at the 2016 expert workshop organised to consider the issues surrounding On-Call service provision in all areas of respiratory Physiotherapy across the United Kingdom.

The consensus opinions of the workshop were collated and the following recommendations for On-Call service provision were generated from this.

Explicit thanks is given to those who attending the workshop and were instrumental in the recommendations, including Carley King, CSP Professional Advisor. Thanks is also extended to the group who delivered the previous ACPRC On Course for On Call Project, including MA Broad, Beverley Harden, Matthew Quint and Sandy Thomas.

The Chartered Society of Physiotherapy have been involved in supporting and reviewing this project and document, giving endorsement of its final content.

ACPRC Respiratory On-Call Position Statement

Introduction

On call services have been established within NHS services for decades. Such services have been staffed by all grades and specialties of Chartered Physiotherapists to provide acute and unplanned Assessment and Treatment of adult and paediatric patients. Within such services there are often specific arrangement for the frequency of on calls, different skill mix of staff and different patient acuitydepending on the local services and staffing structure. Moreover the climate of the NHS has also led to some services being challenged, reduced or removed in an effort to make financial savings or to minimize impact on staff. As a result, numerous clinicians have come forward registering concerns and questions about such services.

It is our vision that all trusts providing acute medical and surgical services should ensure patient access to respiratory physiotherapy 24 hours a day, seven days per week.

Purpose and Intention

The purpose of this document is to provide a comprehensive overview of the role of respiratory physiotherapy on call services. This position paper formalises the consensus of experts within the field of the issues surrounding on call and provides clinicians and managers with a resource to support this important role.

It is intended that this document will generate discussion between commissioners and service providers regarding the provision of on call services to ensure that the service is of high quality.

This paper is a preliminary attempt to define and promote the role of on call services as part of the management of patients in acute services. The working group acknowledges that the document will have limitations, given that services across the UK are diverse in terms of skill mix and patient dependency. However this paper attempts to provide information to support the fundamental factors of an on call service

.

Key recommendations

  • All trusts providing acute medical and surgical services should ensure patient access to respiratory physiotherapy 24 hours a day, seven days per week.
  • The service must be staffed by qualified physiotherapists who are competent to assess a respiratory patient and deliver the respiratory interventions required.
  • Competence should be ensured through the practical maintenance of clinical reasoning and clinical skills and not just through theoretical updates.
  • An On Call service can be staffed by both respiratory physiotherapists and non-respiratory physiotherapists as often it is not possible to maintain a robust service without these staff members
  • Whilst the ACPRC appreciates the challenges of on-call duties to non-respiratory staff we recommend that managers take appropriate action to optimise training and support rather than to put a potentially life-saving service at risk by reducing staffing numbers by not including such staff on the rota
  • ACPRC recommends that all staff should undertake an on-call duty at least once in a six week period ensuring that they complete at least 8 duties per year
  • The ACPRC is clear that the key to maintaining a service and justifying its worth is in collecting appropriate and meaningful data and in ensuring that when on-call physiotherapy is provided, it is delivered in the most effective way (see appendix on suggested data to be collected).
  • Compensatory rest is designed to ensure that staff who have worked during the night and been deprived of sleep due to on-call duty, are not placed in a situation where they are risking their safety or their decision-making due to fatigue. Managers have a responsibility to ensure that the safety and wellbeing of both staff and patients (being treated by a physio deprived of sleep) are paramount when designing their own compensatory rest arrangements (see page 9 for further information).
  • ACPRC acknowledges the historical work completed within on-call competency and training (eg: On Course for On Call). To complement this a project to develop education resources to support general respiratory competencies will be delivered over the next two years. ACPRC is happy to provide advice and support to members about developing education and competency for on call training

Definition of On Call

On-call systems exist as part of arrangements to provide appropriate service cover for acute respiratory patients outside of core working hours.

A member of staff is on-call when, as part of an established arrangement with the employer, the employee is available outside their normal working hours – either at the workplace, at home or elsewhere – to work as and when required.

Position Statement

All trusts providing acute medical and surgical services should ensure patient access to respiratory physiotherapy 24 hours a day, seven days per week. The service will, by necessity, involve out of hours and night time working; however the extent of this will be governed by the structure of the 'in hours' services e.g. Seven day services or twilight services may reduce the on-call hours.

The service must be staffed by qualified physiotherapists who are competent to assess a respiratory patient and deliver the respiratory interventions required. Staff must be proficient in the use and operation of equipment that is used as an adjunct to respiratory physiotherapy in that on-call environment. Competence should be ensured through the practical maintenance of clinical reasoning and clinical skills and not just through theoretical updates.

Patient safety and optimal patient outcome are the most important considerations in service delivery. Moreover the health, safety and wellbeing of the staff participating in this service should be considered in parallel, including adequate time and facilities for rest alongside the appropriate financial reward, and should form the basis of all service designs.

On-Call Service provision.

These recommendations are designed to assist senior Physiotherapists and service managers in ensuring their On-Call service is fit-for-purpose and supports staff and patients appropriately.

Non respiratory staff on the on-call rota

There are many benefits to non-respiratory staff working on the on-call rota; these include:

  • ensuring staff maintain a balance of acute v non acute work;
  • maintains skills in current situation where patients generally are becoming more complex;
  • ensures all staff have skills to treat acutely unwell patients who may be seen in any environment;
  • provides evidence of broad skills so positive for theclinicians CV;
  • good carryover with clinical reasoning into other clinical areas;
  • offers training & CPD opportunities;
  • sets a good example to more junior staff;
  • good for MDT relationships;
  • builds team working ethos within the Physiotherapy department if all staff are on the rota;
  • allows us to share the work of our professions and the benefits of our role;
  • keeping senior staff on call increases option for training.

ACPRC recognises that individual staff may feel strongly that they should not be a part of the On-Call rota. In the majority of cases this is the result of a lack of confidence or training; or a lack of understanding of the importance of maintaining an on-call service with appropriate staff base to prevent burn out of a small number of highly skilled staff.

Whilst the ACPRC appreciates the challenges of on-call duties to non-respiratory staff we recommend that if it is not possible to maintain a robust service without these staff members, then the appropriate action is to improve training and support rather than to put a potentially life-saving service at risk by reducing staffing numbers. (Please refer to recommendations on training.)

ACPRC recommend that an on-call rota should have a minimum of 15 staff at any one time which would mean staff perform no more than three overnight duties per month allowing for leave and sickness.

Part time staff

Some Trusts do not include part time staff less than 0.5WTE due to the maintenance of competencies, time to be released etc.

ACPRC recommend that if the part time staff member is based in a respiratory environment or acute ward environment then they should be included in the on-call rota on a pro-rata basis as a minimum requirement. (Some trusts may include these staff on the rota in the same ratio as staff on greater hours). If the part time staff member is not based in an acute ward or respiratory environment then the time requirement to maintain skills appropriate to the on-call role may impact significantly on their hours in their core role. Such situations should be considered by their line manager on a individual basis to decide if the staff member can carry out their core role alongside adequate training required for on call. Staff returning to work part time following maternity leave should be reminded that an application for part time working should also consider the impact of part time working on any previous on-call role.

Minimal frequency of on call duties

ACPRC recommends that all staff should undertake an on-call duty at least once in a six week period ensuring that they complete at least 8 duties per year. This should be same for all staff on an on-call rota.

Senior staff participating in On-Call

ACPRC recommend that senior grades of respiratory staff (Band 7 and Band 8a) should participate in the on-call rota (on a pro-rata basis if necessary) despite this perhaps meaning they carry out on-call duties at a pay band lower than their substantive rate. This recommendation is already carried out by the majority of departmentsand it is the belief of the ACPRC that this promotes the value of an oncall service to junior staff and ensures the rota has both experienced and junior staff.

Withdrawing an on-call service

ACPRC are aware of trusts that have considered the withdrawal of their on-call service. ACPRC feel strongly that this could potentially cause harm to acute respiratory patients who would therefore not receive essential acute respiratory assessment and/or input.

Of these trust, ACPRC are aware that few have carried out this process and some of those who did withdraw services have since reinstated them.

ACPRC is clear that they key to maintaining a service and justifying its worth is in collecting appropriate and meaningful data and in ensuring that when on-call physiotherapy is provided, it is delivered in the most effective way (see recommendations below).

Be prepared to consider changes to your service, such as withdrawal from less acute sites or introduction of a twilight service.

In general, physiotherapy on-call services are less costly than many other models of hospital on-call service provision and this will work in your favour during negotiations.

The following recommendations will be of assistance:

Data Collection

  • ACPRC advises that service managers collect callout data continuously. However, if this is not normal practice, you should ensure all calls are carefully logged for a six to twelve month period to take account of changes in demand with seasons. This log will allow you to justify the on-call provision based on patient outcomes, identify any patterns of on-call referrals and to highlight potential for changes in service provision such as a twilight service. (See the example log in Appendices)

This log should state:

-times of calls

-who made the referral

-reason for call out (statement of the potential harm the patient was a risk of)

-Information was given to physio by referrer

-The decision by the physiotherapist to attend/not attend

-Outcome of assessment by physiotherapist

-Intervention given, including phone advice if relevant (see example log in Appendices).

Understanding of reason for change in service provision

  • Understand the drive for challenging the on-call service. Is it financial or is it a workforce issue or is the existing service understaffed? This will trigger the focus of your response and ensure your business case appeals to the management issues. Never underestimate the value of the quality agenda and the cost, both financial and legal, of poor patient outcomes associated with the withdrawal of a relatively inexpensive service.
  • Involve your stakeholders in justifying your service – discuss with consultants, obtain patient or relatives accounts of the benefits on on-call physiotherapy and document or incident report any situation where on-call physiotherapy was not involved and could have made a difference.
  • Revisit your on-call policy and ensure it is robust. It should clearly state what profession and grade of staff may activate an on-call referral (this may differ for specialist wards where a nurse may be appropriate).
  • Carry out training with all new starter ward doctors to ensure they are aware of the on-call service and detail what situations and conditions would be appropriate for emergency respiratory physiotherapy, and which would be inappropriate.
  • Ensure your on-call training for physiotherapy staff is robust and that all staff feel empowered to adhere to policy guidelines on inappropriate referrers and inappropriate referral conditions. Consider introducing a buddy system to support less confident staff in refusing on-call referrals if the situations arises.
  • Investigate directorate specific funding if your on-call log demonstrates high callouts to specialist areas (such as paediatrics, neonatal unit or critical care.
  • Publicise widely what the benefits of physiotherapy are and what on-call physiotherapy can offer that nursing staff are not able to offer.

Compensatory Rest

The legal obligation is defined by the Working Time Regulations (WTR)

1998, Regulation 10 (i) of which states :An adult worker is entitled to a rest period of not less than eleven consecutive hours in each 24-hour period during which he works for his employer.

ACPRC recognises that this is a contentious and challenging issue to resolve and will ultimately be determined by local negotiation. It is essential to ensure your local CSP steward is involved and uses the advice and input of the CSP regional officer to assist in negotiating the best possible deal for staff.

Compensatory rest is designed to ensure that staff who have worked during the night and been deprived of sleep due to on-call duty, are not placed in a situation where they are risking their safety or their decision-making due to fatigue. If compensatory rest is not paid time, then staff are understandably reluctant to take this time, however the safety of patients should be of paramount importance.

It is important to acknowledge that if staff are given compensatory rest (time off during working hours) for on-call duties then they are being paid twice if they are also paid for their on-call duty time. Trusts have the right to offer pay or compensatory rest and not both. In addition to this, electronic staff records may prevent staff from being formally given compensatory rest and pay for on-call duty as some systems would not allow both to be registered.

Solutions to this are as follows:

  • Some trusts have added a percentage to annual pay to allow for compensatory rest
  • Compensatory rest can be given unofficially and not recorded.
  • Most trusts who have implemented compensatory rest have offered a graduated system where the amount of compensatory rest is based upon the time of the call-out (see examples in attached document).

Guidance for on call training.