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Consultant gastroenterologist job planning guidance

Updated on: 04 Aug 2020   First published on 04 Aug 2020

Recommendations

General

Good job planning should be undertaken in a positive and constructive manner by both the gastroenterologist and their employer. The aim should always be to benefit patients, staff and the wider NHS. It should be negotiated and fully agreed by both parties. It should not be imposed.

The BSG believes that patients should be at the centre of the job planning process. A key aim should be to improve patient safety, experience and outcomes. Staff must also be a key focus, the job planning process should help motivate, develop and retain staff to ensure sustainable high-quality services.

Consultant job planning must be aligned with the terms and conditions of the national consultant contract.

It should be emphasised that this guidance will continue to evolve over time particularly given the rapid changes in healthcare provision necessitated by the COVID-19 pandemic.

Out-patient work

An out-patient clinic taking four hours (3.75 hours in Wales) in total is equivalent to 1 Programmed Activity (PA) of Direct Clinical Care (DCC) and should include time for all necessary administrative tasks such as making notes, dictating and ordering investigations. New patient appointments should be allocated at least 30 minutes, and follow-up appointments 20 minutes. These times should reflect the needs of the patient rather than the experience of the gastroenterologist. The time involved in undertaking a virtual clinic is unlikely to be any less than that taken reviewing patients face to face (even though there is no physical examination).

Clinical administration

Clinical or patient-related administration (DCC) can be considered as “predictable” (directly linked to fixed clinical care commitments such as clinic letters, review of results etc.) or “unpredictable” (calls/emails from patients, GPs, colleagues, asynchronous consultations- defined as a consultation where the patient and clinician interaction occurs at different times eg enhanced specialist triage, advice and guidance etc). Each needs to be considered separately in calculations of total clinical activity. Work diaries will be particularly useful in the calculation of “unpredictable” clinical administration.

The BSG recommends that patient-related administration is allocated a minimum of 1.5 PA (DCC) for a 10PA job plan for a full-time Gastroenterologist or Hepatologist. Considering the increasing number of patients each Consultant is responsible for, despite not physically meeting many of them, it is quite possible for 2.5 PAs (DCC) or more to be required to appropriately manage the workload.

Endoscopy

One session of endoscopy should equate to 1PA (DCC, 4 hours) and this should allow adequate time for changing in and out of scrubs (and personal protective equipment), team brief, WHO checklists, associated administration including report writing and booking investigations, patient reviews and communication. The content of lists should be adjusted according to the experience of the endoscopist and the anticipated clinical workload (including training, therapeutic and complex procedures, surveillance etc.)

In-patient work

Models of in-patient care have become increasingly complex with many organisations adopting extended shifts (e.g. consultant of the week and its variants). This important work must be appropriately reflected in any job plan with careful consideration to protect consultants from clinical conflicts (e.g. being expected to deliver emergency and planned care simultaneously).

Emergency work (including on-call)

Emergency work encompasses both predictable (weekend ward rounds) and unpredictable (on-call and emergency endoscopy) activity. Each needs to be calculated separately. The BSG recommends that every Trust/Health board aims for an on-call/weekend frequency of no more than 1:8.

Scheduled and emergency weekend working must incorporate an appropriate amount of compensatory rest (in line with the European working time directive).

Supporting professional activities

The BSG supports the RCP recommendation of an absolute minimum of 1.5PAs (SpA) for each consultant to sustain their professional standing (i.e. revalidation and appraisal). Less than full time (LTFT) posts require equivalent time for revalidation, appraisal, study and professional leave. This requires case by case consideration.

The BSG believes that Supporting Professional Activity (SpA) should incorporate the increasingly import role of mentoring. Appropriate time needs to be acknowledged for both senior clinicians (as mentors) and newly appointed consultants (as mentees).

Support of regional and national work

The BSG believes that every consultant should be encouraged to contribute to the wider needs of gastroenterology and the NHS through involvement in recognised regional, national and international associations and collaborations.

Introduction

Consultant job planning remains a fundamental contractual requirement for consultants and associate specialist doctors. This is becoming an increasingly complex process with the more varied and flexible roles of senior clinicians and the implementation of a plethora of both clinical and non-clinical IT systems (including e-job planning applications). More recently doctors work patterns have had to undergo significant change at pace in response to the Coronavirus 19 (COVID- 19) pandemic caused by the infectious disease that results from severe acute respiratory syndrome coronavirus 2 (SARS -CoV-2)  (this will be referred to COVID-19 in this document). This has accelerated changes to clinical practice such as the use of telephone clinics or virtual clinics (where IT systems provide video images as well as sound to enable clinics to be carried out at a distance).

No single guidance document could encompass all possible scenarios and calculations to cover all potential job-planning issues, but this guidance should provide the basis for discussion in the vast majority of situations.

Over recent years there has been an increase in Trust mergers, often with pre-existing, and at times very different approaches to job planning, the use of this guide should help to provide consistency.

The BSG believes that patients should be at the centre of the job planning process. A key aim should be to improve patient safety, experience and outcomes. Staff must also be a key focus, the job planning process should help motivate, develop and retain staff to ensure sustainable high-quality services.

Key elements in a job plan are (1, 2, 3 & 4):

  • objectives
  • direct clinical care
  • on-call and emergency work
  • supporting professional activities such as clinical audit participation, case note review and other activities relevant to the individual’s revalidation
  • additional responsibilities and duties
  • external duties
  • private professional services
  • fee-paying services
  • travel time
  • annual leave and study leave
  • supporting resources.

This guide is aimed both at individual consultants and at clinical directors/job planners with patient care and high-quality service provision at its centre. It is applicable to all four Nations in the United Kingdom and where appropriate specific inclusions or exclusions are mentioned to reflect differences in approach. It outlines recommendations to support both the establishment of an initial job plan, such as that which would be adopted by a newly appointed consultant gastroenterologist and recommendations that support more complex job planning processes for those consultants who have taken on a range of roles. It aims to provide information on a range of current potential issues such as short to medium term changes in response to a pandemic, out-of-hours cover for GI bleeding, seven-day services, team job planning, patient related administration, electronic job planning and less than full time working. It includes some definitions and some worked examples that are aimed to both help understanding and also to assist with individual job planning situations.

Good job planning should be undertaken in a positive and constructive manner by both the gastroenterologist and their employer. The aim should always be to benefit patients, staff and the wider NHS. It should be negotiated and fully agreed by both parties. It should not be imposed.

A job plan is a prospective agreement between the individual doctor and their employing organisation. It should usually take place on an annual basis with timely interim job planning meetings when and if significant within-year changes to commitments or timetabled activity have been introduced, or need to be considered. The BSG supports a more flexible and dynamic approach at times of crisis such as in response to a global pandemic (e.g. COVID-19) but all good job planning principles should still underpin the process.

Doctors are strongly advised to determine PA/timetabling issues and implications with their employer prior to commencing additional work via an interim job plan review. In many cases the process within organisations may not be as prompt or timely as one would ideally hope or expect and so retrospective job planning is required relatively frequently (this is appropriate if overall workload and other commitments have changed above and beyond what was anticipated since the last job planning meeting and an interim job planning meeting could not be arranged).

There are several ways that a doctor’s work might change between job planning meetings not least in response to a global pandemic where widespread and significant changes might be required. A doctor may choose to undertake a new activity without prior job planning or line management agreement, they may be asked to undertake a new activity and there are times when a doctor may feel they must take on an additional activity in order to maintain patient safety and high-quality care. In rare and specific situations, a consultant may be requested to “act down” for short periods, usually single shifts to cover absence of training grade doctors. This issue is beyond the scope of this document. Consultants faced with such requests should access the BMA ‘acting down’ policy and local policies which will assist with emergency clinical work arrangements.

If a Gastroenterologist chooses to take on a new role or activity without prior agreement through personal interest or because they believe it is in the wider interests of patients or the NHS then the Trust can legitimately decline to pay for this activity retrospectively – agreement should be sought at the next job-planning meeting regarding continuing with the activity in question – where possible we recommend that the Gastroenterologist requests an early job plan review. For external duties, such as work for GMC, CQC, BSG, RCP or BMA prior agreement should be obtained. The BSG strongly recommends that employers consider the important role of consultants in the wider NHS as recognized by the association of Royal Medical Colleges (10). The BSG encourages employers to recognise through appropriate PA allocation in job planning all formal roles within their Hospital or Trust (such as education roles, Clinical Lead and Governance leads) -such roles should not be remunerated through other mechanisms such as CEA awards in England or Discretionary points in Scotland.

The BSG supports the establishment of Medical job plan consistency committees (see – Consultant Job Planning: A Best Practice Guide. NHS improvement revised 2017) 3. NHS Improvement recommends Trusts/Health Boards consider setting up a medical job plan consistency committee (MJPCC) with core membership including Medical Director (or their representative), human resources representative, two LNC representatives and relevant clinical directors. Their purpose is to ensure consistency and an even-handed approach across the trust, as well as compliance with the framework, the contract and all national guidance.

As has been demonstrated by the clinical response to the recent COVID-19 pandemic, clinicians of all grades have to remain constantly flexible and be prepared to change their working practice to sustain their support to patients in ever-changing circumstances. For their part, Trusts need to constantly provide support for consultants and mutually respectful job planning will remain the cornerstone of this crucial relationship.

The new consultant

Newly appointed consultants should usually be initially employed on a 10PA contract if full-time. Trusts should advertise all posts as potential job shares and also offer flexibility to accommodate those who wish to work less than full-time (there is no absolute right to an offer of less than full-time (LTFT) employment but for both equality reasons and in order to both attract and retain the workforce of the future the BSG strongly encourages this option to be offered). A typical 10PA job plan will include 7.5 DCC and 2.5 SpA sessions. In many cases, the new consultant will find that the work commitment required is more than 10PAs worth of work. Common components that are under-estimated at the time of appointment are patient-related administration and in-patient workload along with ad hoc additional emergency cases in endoscopy or clinic. A job plan diary should be kept (12), and an interim job plan review requested once this is complete. New consultants, and ideally all consultants particularly at times of significant change, should be offered a mentor who should be able to support them in the job planning process as well as with the wider aspects of their role and career.

Varied patterns of work

For many, if not most consultants working in the NHS, the weekly timetable is not the same for each week of the year. For some the main difference occurs during on-call days. Many have periods on and off the wards. In addition, many undertake periods as the Gastroenterologist of the day, week or month (GOD, GOW or GOM). In most of these situations it is best to consider the weekly PA allocation for each weekly timetable (i.e. week one on the wards, week two GOW, week three to week six elective work). The overall allocation should then be based on the average time for each activity, bearing in mind that for weekends, bank holidays and out of hours (7pm – 7am) in England one PA is 3 hours of activity, not 4 hours as for the daytime PA. This is one of the reasons why those recording job-planning diaries should be encouraged to complete a full rota cycle in order that they capture the impact of both on-call and on the ward periods. Electronic job planning (discussed below) will calculate the allocation automatically.

Later Careers

The BSG supports the later careers work undertaken by the Royal College of Physicians. The NHS needs to retain the expertise and experience senior consultants and this should include utilising their skills in leadership, teaching and training, mentoring and coaching of more junior consultant colleagues and other NHS staff. For example, it is becoming increasingly the case that newly appointed consultants will require additional training and support to develop skills in ERCP, therapeutic endoscopy, hepatology and nutrition.  As more experienced consultants are increasingly needed in these varied supporting roles consideration needs to be given to increasing their SpA allocation to allow adequate time for this type of work.

Trusts and Health boards need to recognise that out of hours cover becomes increasingly challenging as staff age and consideration should be given to adjusting commitments from the age of 55 (earlier if there are significant or relevant health issues). The BSG believes that retaining consultants on overnight on-call rotas beyond the age of 60 should only be by mutual consent. For more information please see – ‘Later Careers: Stemming the drain of expertise and skills form the profession. RCP 2019’ (6)

Download full guidance below.

 


Bernard Brett and Jeremy Shearman

On behalf of the BSG Job Planning Advisory Group* and the Clinical Services and Standards Committee.

*The BSG Job Planning Advisory Group comprises:

Dr Bernard Brett, Consultant gastroenterologist, Norfolk and Norwich University Hospitals NHS Trust

Dr Jeremy Shearman, Consultant gastroenterologist, South Warwickshire NHS Foundation Trust

Dr Tony Tham, Consultant gastroenterologist, The Ulster Hospital, Immediate past chair of BSG Clinical Services and Standards Committee (CSSC)

Dr Alistair McKinlay, Consultant gastroenterologist, Aberdeen Royal Infirmary, BSG President

Dr Andrew Douds, Consultant gastroenterologist, Norfolk and Norwich University Hospital, BSG CSSC Chair

Dr Rupert Ransford, Consultant gastroenterologist, Wye Valley Trust. BSG CSSC Deputy Chair

Dr Melanie Lockett, Consultant gastroenterologist, North Bristol NHS Trust, Previous BSG Workforce Lead

Dr Helen Fidler, Consultant gastroenterologist, Lewisham and Greenwich NHS Trust, BMA Council Deputy Chair

 



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