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Last Updated: Monday, 29 August 2005, 23:16 GMT 00:16 UK
The quiet revolution of NHS night care
By Nick Triggle
BBC News health reporter

The Moon
The Hospital at Night project started in 2003
By evening most people are winding down, perhaps thinking about getting ready for bed.

But for the doctors and nurses who staff hospital wards at night the work is just beginning - after all, people do not just get sick during the day.

The way the NHS works at night is undergoing a quiet revolution as it tries to reform archaic working practices to meet EU rules on working hours.

By 2009, no junior doctor should work more than 48 hours. In the past 60, 70 and 80-hour weeks have been common.

The traditional approach to staffing a hospital at night has been to station nurses and junior doctors on departments for the night.

Doctors

But critics have argued that the system was not making the best use of staff as some were positioned in wards where there was little to do.

Also, nurses were often not trained to deal with many of the problems that arise, and therefore had to bleep a junior doctor, who then either had to treat the patient themselves or call a more senior doctor, such as a consultant.

Under the new model - piloted by four NHS trusts since 2003 and now adopted by more than 20 other hospitals - a "multi-disciplinary" team works across the hospital where needed.

HOSPITAL AT NIGHT
Staffing - Instead of getting staff to work in an individual department, the joint team works across the hospital where needed. Generally, the number of nurses has increased, while there are fewer junior doctors
Handover - Representatives from the night and day teams meet as the shifts swap to discuss what is happening. Under the old methods staff were just expected to 'pick it up'
Bleep filtering - Nurses are able to take on more responsibility, which means they need to bleep doctors less and when they need to, they know who to bleep

The pilots, which all differ slightly, have increased the number and skills of nurses working at night, which has in turn allowed bosses to reduce the junior doctors on call.

Dr John Coakley, medical director at Homerton University Hospital in east London, one of the pilots, said while the system still needed a little tweaking, it provided the NHS with the best way of adapting to the changing working culture.

"Junior doctors are used to working long hours, but like it or not, that has to change.

"Since we have introduced it, we have had nothing but positive feedback from staff and patients.

"The standard of care is better, because we know more about what is happening."

Cover

Before introducing the changes, the hospital spent six months carrying out an audit of what happened at night, looking at A&E, orthopaedics and intensive care, to determine what sort of cover was needed.

In the end they set up a team to work across all departments, doubling the number of nurses on duty, which in turn has meant that two fewer junior doctors needed to be on call.

The nurses have also undergone specialist training to allow them to take on more responsibility, such as administering drugs and doing blood tests, meaning there has been a 60% reduction in the number of times doctors are being bleeped.

The problem is that some trusts have seen it as an opportunity to cut costs
Andrew Thompson
British Medical Association

The hospital has also improved the transfer from day to night staff. Traditionally, the night crews have had to "pick it up" as they went along.

But the Homerton, a foundation hospital, has set up a handover meeting where medics from both shifts discuss what is happening.

"Much of it is commonsense really," says Dr Coakley. "It seems amazing this hasn't been done before."

These sentiments were echoed by an independent report for the Department of Health earlier this month.

It found that across the four pilots - the Homerton, Royal Liverpool and Broadgreen NHS Trust, Wirral NHS Hospital Trust and Morecambe Bay Hospitals NHS Trust - care had improved, while there had been no harm to doctor training or meeting targets.

Modernise

Public Health Minister Caroline Flint said the EU working-time directive had presented the NHS with a great opportunity to modernise.

She added: "Hospital at Night prioritises acutely ill patients, and ensures that patients are treated more quickly and are seen by doctors who are more alert."

And the NHS Confederation, which represents health service managers, has urged more trusts to adopt it.

A spokeswoman said: "Hospital at Night is a major step forward, both in terms of improving patient safety by taking a more systematic approach to care at night and by making a much more efficient use of rotas for medical and nursing staff.

Nurse
A greater number of higher skilled nurses are working at night under the new model

"It is a model that, in some form or other, everyone should be using."

Union leaders have even held up the model as an example for other industries.

Paul Sellers, a policy adviser at the Trade Union Congress, said: "Quite often long working hours are down to inefficient working and managing practices.

"Hospital at Night is a good example of what can be done when you think about how staff are working."

But not everyone is confident about the way the new system is being rolled out.

Andrew Thompson, of the British Medical Association's junior doctors committee, said while the pilot hospitals had introduced the reforms in a positive way, many of the others that had followed suit were trying to get "health care on the cheap".

"The problem is that some trusts have seen it as an opportunity to cut costs. They have not really done the research and looked at what staffing is needed, nor have they done the training to skill the nurses," he said.

"They have just seen it as an opportunity to cut numbers and that will harm patient care."




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