In the UK, the care of hospital patients out of hours has traditionally relied on specialty specific tiers of doctors working “on call” rotas.

However the European Working Time Directive (EWTD) has prompted a fresh look at the way safe and effective care of patients is delivered out of hours in hospitals.

In 2003 the NHS Modernisation Agency commissioned a pilot study of the Hospital at Night model of care in four NHS acute hospital Trusts encompassing 8 hospital sites. Since then this model of care has been rolled out to several more hospitals. Hospital at Night provides clinical care at night through a multi-disciplinary team (or teams) competent in providing a wide range of interventions but able to call in specialist expertise when needed. Other important aspects of the scheme are a multi-specialty evening handover, extending the role of staff to relieve doctors of certain tasks, bleep filtering, moving some non-urgent work to the daytime or evening and improving co-ordination to reduce duplication of effort and work. The team co-ordinator is generally a senior nurse and the composition and skills of the team are determined by the type of patient being cared for.

The good news
A recent evaluation of the Hospital at Night pilot project was extremely encouraging: doctors felt better supported, their work loads were less intense, there were some positive effects on training and education, patients were seen more quickly by the most appropriate person and there was no deleterious effect on patient care or performance targets1.

The bad news
However at the recent trainees’ meeting of the British Geriatrics Society Autumn Meeting 2005, many trainees expressed concern about Hospital at Night arrangements which they relayed to the Education and Training Committee (ETC) through their representative.

Their main concerns were:

• The on call medical registrar is invariably the medical lynch pin of the team, and as a result can be very stretched supervising the take as well as providing senior cover for additional (surgical) wards at the request of the team co-ordinator
• Very junior doctors were missing out on some aspects of training as practical skills were being undertaken by other staff
• In some hospitals although doctors had altered their pattern of work, nurse practitioner support was variable and in some cases extremely poor

In the light of these concerns the BGS Education and Training Committee (ETC) undertook a quick survey of opinion on Hospital at Night through deanery Geriatric Medicine Specialty Training Committee Chairs.

Good and bad
It is clear that opinion is very much divided about Hospital at Night. In many Trusts this model of care is working extremely well and there are several examples of good practice e.g. one hospital in Lanarkshire incorporated nurses with considerable specialist expertise (ITU/CCU) into their team. However other respondents expressed concern. One registrar reporting working “flat out without a break for 13 hours”.

The strongest recommendation was that a successful Hospital at Night team needed considerable advance planning before implementation.

As this is such an important subject the ETC felt it would be valuable to undertake a more formal survey of specialist registrars. This will be co-ordinated by David Hargroves, one of the SpR representatives on the ETC.

We hope the survey will identify aspects of good practice which can be shared with others as well as any problems associated with Hospital at Night.

The survey will be inserted into the March Newsletter, and will also be online on the BGS website. We would greatly value your response as your opinion matters.

Oliver J Corrado
Chair Education and raining Committee