This guidance should be adapted for local use as circumstances will vary from hospital to hospital. During the normal working week, many of these support services are relied upon implicitly as just “being there” when required. This page aims to highlight these support services, as during this period they may not be immediately available. Also, due to the reduced number of consultants at work, there will not be the same resilience should two emergencies happen at once. This needs to be considered for elective care planning on strike days.
Providing any elective activity will be very challenging
The BMA and NHSEI have jointly written to trusts outlining that the consultant strike action is very different to other periods of strike action and that this presents significant challenges in undertaking elective activity. The BMA view is that elective activity should not be undertaken during the strike days and gave 6 weeks’ notice of the dates of action in order to ensure patient lists could be managed in advance.
Need for risk assessments
However, the BMA/NHSEI letter outlines that for any planned activity to go ahead, a full risk assessment must be undertaken to ensure that the necessary services that may be required in an emergency are available. The risk assessment must outline which consultant from each speciality is providing this cover. This must be a consultant other than the on-call consultant as the BMA derogation for emergency cover only applies to services available on a Christmas day and this on-call consultant may be off site or dealing with other emergencies.
The joint NHSEI/BMA guidance explicitly states:
“[I]t is important that trusts and staff work across teams to take a whole pathway approach to determine what, if any, elective activity can safely go ahead, particularly for surgical or other procedures.”
“Trusts should not plan activity on the assumption that the emergency cover consultant will provide cover as the BMA are clear that the derogation allowing emergency care to continue only extends to services that would run on Christmas Day.”
It is also important to highlight that whilst other medical staff such as junior doctors, specialty doctors and locally employed doctors and other non-medical staff are highly skilled and vital members of the team, they are not autonomous workers. They must not be asked to work outside their areas of competence and must have clear supervision arrangements in place from a named consultant. For the reasons outlined above, this must be provided by a consultant other than the on-call consultant.
This is reiterated in the joint NHSEI/BMA guidance.
“Almost no activity in a hospital can occur unless it is listed under and supervised by a named consultant. Non-consultant and non-medical staff should not be put in a position where they are asked to perform elective work where this is not under the direction of a named consultant or outside of their competencies. If such activity goes ahead appropriate consultant support must be available and this must be provided by a consultant other than the on-call consultant”
We have outlined a number of scenarios below, but this is not designed to be an explicit list and not all risks/considerations will be relevant to every patient. They are listed in no particular order.
Elective surgery and/or invasive procedures
As part of the consent process, all patients will be informed of potential complications during the operation or procedure. As a minimum, trusts and the consultant staff responsible for performing the operation/procedure must outline the necessary support that may be required should one of these recognised complications occur.
For example, this may include vascular or interventional radiology in the event of a bleeding complication, support from another surgical speciality, intensive care admission, cardiology support, renal support etc. For each of the applicable specialities that may be called upon in the event of complications occurring, the named consultant for those specialties should be documented and it should be clear how this support will be accessed. In some cases, these support services will be provided by partner units or tertiary centres, and it is essential that there is agreement between Trusts regarding these arrangements where required.
Patients also have the right to know that consultant support for the management of complications or additional support services may not be as readily available as normal. The NHSE/BMA guidance quoted above says:
“Patients undergoing surgery or invasive procedure should be appropriately consented and informed that the consultant strikes are occurring and there will be reduced support available in the event of complications.”
Where there is a planned mitigation of the risk, this should be conveyed to the patient because they may have concerns if they are aware strike action is happening, and it will be reassuring for them to know that the risks have been considered and mitigated.
All risk assessments must be signed off by the medical director.
Checklist for surgical/invasive procedures
- Confirm that there is a named consultant performing or supervising the operation/procedure Y/N
- Is there a named consultant anaesthetist performing/supervising the procedure? Y/N/NA
- Is intensive care support available if required? Y/N/NA
- If yes, please provide details
- Are radiology services required? Y/N/NA
- If yes, please provide details
- Are pathology or microbiology services required? Y/N/NA
- If yes, please provide details
*NB If the answer to any of the above questions is yes, a named consultant other than the on call consultant must provide/supervise this service. The activity cannot go ahead without this in place.
- Has the additional risk above been discussed with the patient (per Montgomery vs Lanarkshire Health Board) and documented? Y/N
- If no, what is the reason for not doing this?
- Please list the recognised complications that the patient has been consented about below and outline the specialities that may be required, the named consultant for that speciality, and the method of contact:
|Complication*||Support Speciality||Named Consultant||Contact method|
|e.g. haemorrhage||Interventional Radiology|
* As a minimum this should include all complications for which the patient is consented but also any other generic services such as cardiology, radiology, renal, endoscopy in the event of complications
Senior colleague support for registrar outpatient clinics
Senior registrars (pre-CCT) sometimes run an outpatient clinic on non-strike days with distant consultant supervision, where that consultant is readily available for discussion of complex cases and takes responsibility for patients requiring admission. It is essential to note that this consultant supervision must be available and should not be provided by the on-call consultant. Furthermore, if a consultant is striking, no activity can occur “in their name” and a registrar cannot undertake a clinic on behalf of a consultant that is striking. If this clinic goes ahead, another named consultant must supervise the clinic in their name and assume responsibility for these patients including any consequential care.
- Is there Consultant Supervision in place for this outpatient activity? Y/N
NB this must be provided by a consultant other than on call consultant and the named consultant must take responsibility for these patients including nay consequential care. Activity cannot take place under the name of consultant that is striking.
Anaesthetic support for local anaesthesia and/or sedation cases
Cases performed under local anaesthesia or sedation occasionally deteriorate and require immediate or urgent anaesthetic support, either because of surgical complications that require general anaesthesia to rectify, local anaesthetic toxicity or other drug reaction, or because of pain that requires anaesthetic intervention to allow surgery to be completed. During the normal working week, such anaesthetic support is readily available but during the strike action, appropriate anaesthetic cover must be identified by the trust before such cases can go ahead.
- Is there anaesthetic support available if required? Y/N
During any surgery, haemorrhage can occur, either anticipated or unanticipated. Management of major haemorrhage requires the input from a variety of services including but not limited to vascular surgery, interventional radiology and haematology. If it is essential to ensure that these services are available.
- What agreed plan is in place for haematology support, vascular support, etc., if haemorrhage should occur on the elective operating list?
Elective surgical procedures can lead to a requirement for planned or unplanned admission to intensive care or HDU post-operatively, for a wide variety of reasons. Risk scoring can suggest which cases are more likely to require this, but unanticipated admissions still occur.
ITUs will be operating on reduced staffing and may not be able to cope with these admissions unless alternative arrangements have been made.
Support services underpinned by consultant support
Other support services in the hospital may be in part delivered by non-medical colleagues but are underpinned ultimately by consultants who provide the final layer of support and expert opinion that the non-medical staff depend on for safe delivery of that service. During the strikes, consultant cover will be very limited and on Christmas Day, this activity would not normally happen. If this activity is to continue it is important that arrangements are in place, from a consultant other than the on-call consultant to ensure that there is support required if needed. In addition, many unduly burdening the support services with elective care that will generate work for them (which will have a small but potentially significant rate of queries that need consultant input) puts the delivery of support for emergency care at risk.
Examples of support services that might be affected by availability of consultant cover include biochemistry, microbiology, radiology, ultrasonography, radiotherapy, endoscopy, echocardiography and midwife/nurse-delivered clinics.