RCoA and Association of Anaesthetists joint statement on winter pressures

Every winter, the NHS faces a crisis as its resources and staff are stretched beyond their capacity, but this year is likely to be the worst for many years. We know that each winter most NHS Trusts and Health Boards exceed their recommended bed occupancy levels and this year the need to separate COVID and non-COVID pathways has made the problem worse. The Chief Medical Officer, Professor Chris Whitty, has predicted “an extremely difficult winter for the NHS — one that I suspect, unfortunately, will be unlike any we’ve seen in recent memory….this is going to be a long and difficult slog.” He has also pointed out that staff are already exhausted due to the demands placed on them by the first surge of the pandemic and the prospect of further surges after this one. 

During the pandemic staff at all levels of seniority have been asked to work in clinical areas that would not normally form part of their practice, thus placing them at risk of moral injury. Whilst redeployment happened at quite short notice during the first surge, anaesthetic departments should now be better prepared and have plans in place for the escalation required at different surge levels. 

The mental health effects of increased work and unfamiliar working environments should not be underestimated. Multiple surveys have been conducted by the College, with the latest showing that 64 per cent of respondents have, to some extent, suffered mental distress of additional and emotionally difficult work related to the pandemic. Anecdotal reports to the Association also found that many have experienced mental hardship due to the increased workload.

The following principles apply to anaesthetists of all grades who are asked to perform clinical duties outside of their normal clinical specialty or outside of their normal environment:

• individual organisations’ winter pressure contingency plans should include clearly defined triggers and operational procedures for the short-term emergency deployment of staff to work outside their usual environment in exceptional circumstances. We have previously issued guidance on cross skilling to prepare clinicians for this
• the decision to deploy staff to work outside their usual environment should only be made by the Medical Director or deputy, in consultation with the Clinical Director and, in the case of anaesthetists in training, the Director of Medical Education and lead educational supervisor. This is particularly important with the likelihood of repeated surges of COVID-19 which will extend the need for redeployment beyond the normal winter pressures
• no anaesthetist should be expected to practise beyond their clinical competence
• anyone working in an unfamiliar environment must receive an appropriate induction and be familiar with local governance arrangements. They should be given a clear line of senior medical supervision that is appropriate to their level of competence. This applies equally to consultants, SAS grades and anaesthetists in training. Both the supervisee and the supervisor should be aware of their roles, their responsibilities to each other and have a reliable means of contact
• any changes to working conditions must be in line with contractual obligations, employment law and national terms and conditions in order to ensure that efforts are sustainable and anaesthetists are not working in a manner that compromises their health, safety or wellbeing, nor that of their patients.

The following points apply to anaesthetists in training:

• Anaesthetists in training who are asked to support the service under pressure should be selected equitably from those who are most suitable to contribute to the area under pressure. The same trainees should not be redeployed successively as this will impact on their training
• deployments should be kept as short as possible and such measures should be planned carefully, with input from local trainers and consideration of the impact on all doctors affected. The College Tutor should be involved in the decision-making and the Training Programme Director, Head of School and Postgraduate Dean must be informed of any movement in all cases. Any movement must be supported by a full hospital and departmental induction
• as far as possible, it should be ensured that these individuals are not disadvantaged at their Annual Review of Competency Progression. Outcome 10s should be used to show where training progression has been delayed by factors related to COVID-19. College Tutors, Regional Advisers Anaesthesia (RAAs) and Association Links are asked to provide or facilitate appropriate pastoral support to anaesthetists in training who are redeployed. The hospital’s Guardian of Safe Working should be made aware of redeployments and any change to hours worked
• if training opportunities are missed because of changed duties, arrangements should be made to access the training in a timely manner. We encourage anaesthetists in training to reflect with their supervisors on the experience of working in these circumstances, so that the issues encountered and any potential for learning can be better understood. 

The College and the Association understand how workload and workforce pressures during these challenging times are impacting clinicians’ health and ability to deliver high-quality patient care. This has been highlighted during the pandemic and reinforces our argument that beyond this winter, and short-term actions to address the current pressures, we require sustainable long-term solutions for over-stretched front-line services. We urge government and relevant bodies to continue to work with us to develop a comprehensive long-term workforce strategy that provides for the necessary investment in capacity, medical training, ongoing wellbeing support and facilities for staff working in NHS hospitals across the country.

Professor Ravi Mahajan, President, Royal College of Anaesthetists

Dr Mike Nathanson, President, Association of Anaesthetists