Introduction As Divisional Medical Director from September 2018 to May 2022 and College Tutor for Medicine from September 2018 to December 2021, I had a unique opportunity to collaborate with senior clinical and operational leaders along with educationalists. I was responsible for supporting the exit flow from the Emergency Department while providing trainees with the best possible support. I focused on three areas for improvement:

1. The process to review medical patients on surgical wards was through a medical locum consultant with trust-grade doctors in 2018.

2. There was a need to develop a model for covering a high number of medical COVID patients in surgical wards because of the impending COVID-19 pandemic in March 2020.

3. Locum staff gave notice to cover two escalation wards in February 2022. Despite considerable efforts to re-appoint locum consultant staff, this was not possible because of the high demand for their services.

Aims and objectives of the research project or activity The key aims of the activity were:

1. Improve patient safety

2. Improve quality of care

3. Improve productivity

The Royal College of Physicians’ guidance on Safe Medical Staffing July 2018 sets out the number of medical staff that could safely care for patients on medical wards. The report recommended medical time to provide safe care for 30 beds was 71 hours of Tier 1, 30 hours of Tier 2 and between 20.5–24.5 hours of Tier 3 ward work. The wards at Medway Maritime Hospital were typically between 18–27 beds, and the cumulative medical staffing time exceeded the safe medical staffing hours recommended in this document. This became the foundation for expanding the performance of medical teams by adopting other areas of responsibility, not just their base medical ward.

However, when the demand exceeded the capacity, other activities were canceled to provide additional medical time to meet clinical needs.

Method or approach I took a continuous PDSA approach to this work with cycles of small change. The activity was undertaken through a collaborative approach and included all leads and stakeholders through regular meetings to receive feedback and constructive criticism, which led to further change. The Clinical Director’s weekly meeting and Monthly College Tutor Team meeting became the driving force for change. In addition, proposed plans were shared with the Clinical Council, management and Executive colleagues and amended accordingly.

We met with our business partners and clinical and operational leads to review the number and grade of medical staff in each medical ward and daily reviewed staffing.

The number of medical patients was recorded on each surgical ward between 2018–2019. Furthermore, the number of total and medical admissions from the emergency department was recorded. The number of COVID patients and their location was recorded on a daily basis over the pandemic.

Findings 1. A system of ownership through medical-surgical paired wards.

Ward   Team     Acute Frailty (index score >5)

Phoenix  Gastroenterology  Milton

Arethusa  Lister     Tennyson

Kingfisher  Endocrinology  Byron

Pembroke  McCulloch  Orthogeriatric Team

Victory   Sapphire   Harvey

2. Average number of medical patients on surgical wards comparing locum activity (2018) to departmental ownership model (2019)

  January  February  March

2018 Average/day  Ave 54 (21–76)  Ave: 46.7 (38–53)  Ave:41.7 (29–54)

2019 Average/day  Ave: 27.7 (21–35)  Ave: 24.4 (18–32)  Ave:23.4 (19–32)

3. Maintaining escalation wards when loss of locum consultant staff: The escalation wards remained open from January 2022 to May 2022 until locum staff were appointed. The template was as follows:

Jade Ward  Ward Team

Bay 1 SR1  Will Adams

Bay 2 SR 2  Tennyson

Bay 3 SR3  McCulloch

Bay 4  Sapphire

Nelson Ward  Ward Team

Bay 1 SR1  Keats

Bay 2 SR 2  Milton

Bay 3 SR3  Lister

Bay 4  Bronte

4.. Medical wards were expanded onto surgical wards during the Covid-19 pandemic. Two medical consultants on each surgical ward with the cancellation of all activity.

Ward  Team

Sapphire/SAFU Covid Ward  Endo/Haem/Frailty

Bronte/Covid Ward  Endocrinology

Phoenix/Covid Ward  Gastroenterology

McCulloch/Covid Ward  Respiratory

Arethusa/Covid Ward  Endo/Gastro

Key messages

1. Improved productivity of medical wards with improved ownership of outlying medical patients.

2. Improved effective cover of medical patients on surgical wards with fewer patients in 2019 compared to 2018, likely from more effective care.

3. Improved cost-effectiveness of the Medical Model with no requirement of a locum consultant physician with Trust doctors to support to cover medical outliers.

4. The Emergency Department moved from an inadequate CQC rating in December 2020 to a good rating in June 2022. This was supported by keeping escalation wards open rather than closing them through no senior medical review of patients.

5. There was a negative impact of loss of other speciality activity, which led to a Covid backlogs.

6. The NHS Long Term Workforce Plan June 2023 will lead to greater expansion of the workforce to provide higher quality and safe care for in-patient ward cover.