The shifts follow the person. Every person has a set number of hours to do, but they can effectively work when they want as long as the group of doctors rostered can cover the shifts needed.
About University Hospitals Sussex NHS Trust
Discover how the UK’s first true annualisation and e-rostering solution supported the A&E and general medicine departments at Royal Sussex County Hospital in Brighton and the Princess Royal Hospital in Haywards Heath, to implement three aims which were previously thought to be mutually exclusive; improve patient care, create a happier workforce, and reduce locum costs
Download Case Study: Brighton tackles burnout (6.98 MB)
Introduction
To provide safe and high-quality inpatient and emergency care, and with the cost of employing locum doctors becoming unsustainable across legacy Brighton and Sussex NHS Trust (Royal Sussex County Hospital (RSCH) and Princess Royal Hospital (PRH)), it was essential for doctors to be deployed in an optimal way, whilst supporting them to achieve a better work-life balance.
Traditional manual systems for planning and deploying the workforce are laborious and open to error. However, new ways of working and the implementation of the digital platform – HealthRota, has provided a more comprehensive approach to staff deployment in line with demand at the trust.
The innovative approach has given staff the tools to manage their time more easily, leading to improvements in morale, flexibility, and patient safety whilst helping the hospitals to completely eliminate planned junior doctor locum costs from August 2022 across A&E and General Medicine wards and on-call rota.
Challenges
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Multiple, composite rotas for hospital doctors
With the individual rota for any given hospital doctor typically a composite of numerous rota’s – encompassing their base ward or department, clinical duties, on-call requirements, outpatient responsibilities, and non-clinical tasks such as medical management, training, research, and teaching, it’s clear to see why medical rotas can be extremely complex to manage.
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Rotas built as spreadsheets
Across many UK hospitals these rotas have been typically managed on spreadsheets which are not built with the functionality to support the complexities of medical rota systems. The outcome for staff is a rigid rota offering little flexibility and making the idea of achieving a better work-life balance an unrealistic prospect.
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Recruitment and retention issues
Due to the introduction of the Major Trauma Centre and the need to provide 24/7 A&E consultant cover, the capacity issues became intensified. Recruitment and retention challenges led to low morale, burnout and general upset for consultants because of the lack of rota transparency and the uncertainty of knowing if they were working the correct number of hours that they were contracted for.
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Compliance with Regulations
Balancing contractual rules and regulations, such as the European Working Time Directive (EWTD) and the Working Time Regulations (WTR) in the UK, poses a significant challenge for rota coordinators. The absence of an automated system makes it challenging to monitor the regulations and ensure compliance for a sizable team of junior doctors.
Solution
Workforce management pioneer and A&E consultant, Professor Rob Galloway, Amy Brown, Senior Workforce Coordinator, and their team, were looking for a way out with a comprehensive solution to all these challenges.
After several attempts to find the right e-rostering solution that truly allowed the use of annualised hours, in 2017, they discovered HealthRota. From here on, the team has worked in partnership with the HealthRota team to create a more intelligent, responsive and bespoke online self-rostering/self preferencing system that incorporates annualisation for the RSCH and PRH.
The team started out by using A&E as a proof of concept, before creating successful solutions for acute medicine and care of the elderly consultants and then all the junior doctors in general medicine wards across both hospitals.
The shifts follow the person. Every person has a set number of hours to do, but they can effectively work when they want
A&E consultant, Professor Rob Galloway
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Initial implementation of annualised pay with consultants in A&E
The team began the roll out with A&E consultants followed by registrars. To do this, they calculated the number of professional activities (PAs) each group were required to do, minus any annual leave, study leave and bank holidays. This provided an accurate figure for the total number of PAs available within the team in a single year (annualisation), month or week. Using this figure, they were able to create a calculated shift structure, balancing staffing with the available PA allocation.
Where clinical demand required additional PAs to be worked, the team could calculate the number of extra consultants and registrars needed, or have clarity on the locum requirements for that period.
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Self-rostering introduced
Based on the annualised PA calculations, consultants and registrars were switched on to self-rostering, enabling them to pick their own shifts. This provided a level of flexibility staff had never experienced before; for example, some opted to work more weekends, whilst others selected early mornings or evenings depending on their personal and professional preferences.
Where a consultant or registrar wished to swap a shift, or simply take on a shift without a swap, the HealthRota platform is able to track change the hours worked (PAs) in real-time and allocate the correct number of PAs to the relevant staff member. With the ability for managers and rota coordinators to view up-to-date information about the work completed, consultants and registrars can effectively overwork or underwork during selected periods.
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Collective responsibility to cover all shifts
Under Professor Galloway’s leadership, the team came together and took collective responsibility for covering all the shifts between them. The agreement being that no shift was left unfulfilled, even after all leave and days in lieu were accounted for, and a key proviso that they did not owe, or were not owed, any PAs when they left their job.
In return, consultants and registrars achieved unparalleled flexibility, a positive and conducive working environment, improved peer-to-peer team working and a more robust support structure for their junior doctors.
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Adapting for junior doctors in A&E
Shortly after, the approach was adopted for rostering junior doctors (senior house officers and F1 level) in A&E. This involved working out annualised hours, obtaining their request for when they didn’t work (self-preferencing rotas) and creating bespoke rotas from basic templates which provided the cover needed, while allowing the flexibility that doctors wanted.
The software also ensured that the doctors only worked the number of hours they were contracted for and worked an equal amount of out-of-hours shifts (which on traditional un-adapted templates is impossible to create).
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Expanding in to General Medicine and Care of the Elderly
Following the successful roll-out of consultants in A&E, acute medical consultants and care of the elderly consultants adopted the same system of annualisation, but adapted it so that they could provide the continuity required for their ward and clinic work.
This improved the department’s ability to recruit and retain staff and improve the well-being of the consultant body. Following this, Professor Galloway and the team created the same benefits for junior doctors (registrar to F1 level) across General Medicine and Care of the Elderly wards, across RSCH and PRH hospitals.
Results
The new approach to rostering in Brighton has led to an overall increase in job satisfaction among doctors, enabling the Trust to recruit and retain a pool of talented and experienced staff.
From August 2022, optimal staffing levels have been calculated for each ward area and A&E department in RSCH and PRH, with clear visibility about the number of doctors required. Due to the flexibility of the rota system, all these shifts have been created and evenly filled.
78 FTE SHO and registrar fellows across medicine and A&E at both sites have been recruited, all with post F2/NHS experienced/UK trained doctors, to work alongside the HEE trainee doctors. The successful recruitment was only possible because people specifically wanted to come to work at RSCH/ PRH because of the flexible rota. As a result, there are no planned locum costs from August 2022, except to cover unexpected sickness. This would not be possible with traditional templated rota systems.
Annualisation with automated PA calculations
Annualised rotas and self-rostering/self-preferencing has created an equal distribution of shifts, reducing levels of burnout and ensuring that doctors only work the hours that they are paid for.
By using a combination of period of activity and hourly contracts for consultants, middle grade and junior doctors, all doctors are empowered with the flexibility to choose the amount of clinical work they wish to do.
In comparison to traditional rostering systems, the new approach means that rotas are created and structured only after all types of leave have been calculated. This provides the flexibility that staff have asked for, whilst maintaining the principle that shifts are distributed equally, regardless of the day or ward area. It also helps to create rotas that are planned to be locum free, saving the Trust millions of pounds each year.
Greater flexibility and work-life balance with self-rostering
With doctors able to mark themselves as ‘unavailable’ or ‘available’ using the HealthRota application on their desktop or mobile devices, emergency and medicine departments can operate a fully flexible and bespoke rota system that is almost entirely locum-free (except for last- minute sickness).
Shift swapping provides the functionality to utilise available staff more efficiently, rather than relying on the fixed and inflexible templates of the past. Staff have their rotas emailed directly to their online calendar and can easily swap shifts, request annual leave and self-roster independently – all via the mobile app, giving them greater ownership and control over their own time.
Enabling a successful crisis response during the Covid-19 pandemic
With the HealthRota e-rostering system already in place and demonstrating significant benefits prior to the Covid-19 pandemic, the Trust made the decision to roster the entire junior workforce onto the platform using annualised rotas. This allowed the team to seamlessly initiate a crisis response which prevented doctors moving between wards by providing a temporary base ward. Each ward was rostered with nine doctors, providing cover for 24 hours-a-day, 7 days-a-week. This allowed the Trust to honour 100% of the doctor’s annual leave entitlements and enabled staff to take time off when they requested.
Amy said: “It saved us. It was amazing.” She adds: “If you can imagine a control room with your Chiefs planning your team, that is what we did. We were able to stop everyone from moving around and still ensured our workforce got regular breaks, their annual leave when requested and that we still had sufficient capacity to meet the demands of the Covid pandemic despite the number of staff not able to work. We built resilience into the team and so during wave one, not one doctor felt that they were being overworked. It was unbelievable.”
Benefits
- All rotas are annualised, with all types of annual leave, days off in-lieu, and non-shop- floor time is factored into the rotas. From August 2022, the only locum requirements are to cover unexpected sickness across A&E and the medical wards.
- All available posts have been recruited for, with locum savings used to fund and improve staffing levels. In five years, the Trust went from seven consultants and seven registrars (for two sites) to 23.8 full-time equivalent (FTE) consultants and 20 registrars.
- The Trust benefits from 24/7 consultant A&E cover at Brighton, and cover between 8am and 10.30pm every day of the week at the Princess Royal hospital.
- The cost of using locum doctors has been curtailed. For example, before the annualised rota system was introduced, £1.3m was spent on locums at RSCH and PRH in A&E alone. The year after annualisation was implemented (2018), the locum costs were less than £50K.
- For 2022-23, the only projected locum need is to cover sickness absence. This is projected to be less than 300K a year for the whole of A&E and medicine across two sites.
- With objective data available for capacity and demand planning, and with self-rostering and annualisation cited to be a positive factor for staff teams, it has proven easier to recruit UK trained post F2 doctors to clinical roles.
- The Trust has the data available instantly to assess who can cover shifts or who is available should a major incident occur.
- The administrative time required to run rotas has been drastically reduced.
- Aside from any ongoing challenges of Covid-19, A&E and general medicine is almost consistently run with the staffing it needs. This has enhanced out-of-hours cover, improved clinical safety, patient experience and outcomes.
- Doctor wellbeing has improved with burnout rates falling significantly due to better work-life balance and the flexibility to work when preferable, with easy access to self-rostering on the HealthRota app.
- The learning environment has been enriched with more support available for junior doctors. The Trust has been able to recruit clinical fellows who work 75% clinical time, and 25% non-clinical time in areas such as research, simulation and education.
- With 44 FTE educational fellows delivering over 16,000 hours of undergraduate education, the Trust has positively impacted on the education of its medical students, transforming feedback of students. The administration team roster the educational fellow’s rotas to ensure that there are fellows available when the students are on placement. In 2021, Brighton and Sussex Medical School came 3rd in the national student survey for medical school with
staff teams, it has proven easier to recruit UK trained post F2 doctors to clinical roles. - The Trust has the data available instantly to assess who can cover shifts or who is available should a major incident occur.
- The Trust now has 14 research fellows starting multiple projects in line with the Trusts’ key research objectives.
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