On Calls for Doctors working in NHS

An important part of working in NHS is on calls. Now the type of on calls that we are used to doing in our home countries is significantly different than how things run here. Read on to find out how exactly the system works so when you start your on calls you already have an understanding.

Admission Process

To understand what you are meant to be doing on call you need to understand the admission process of patients into the hospital. Patients get admitted through three sources

• Emergency Department : Patients are brought in by Ambulances

• Emergency Department : Walk ins

• Referrals from GP : Clinics

• Referrals from GP : Urgent Care Centers

• Outpatient Clinics

• Day cases

• Referrals from other hospitals

Day cases and some non urgent GP referrals usually directly go to wards whereas rest go through A and E. Hospitals in UK have a specialty that deals with acute medical cases known as Acute Medicine. Almost all medical admissions directly go to Acute Medical Units (AMU) from A and E where they are managed for 24 - 48 hrs before being sent to medical wards. Critical care patients can go ITU, CCU, HDU either from A and E or AMU.

Thus these patients need to be assessed and clerked by medics this is where you step in. But since it's a hospital patients will be coming in but there will be patients who have already been admitted that needs to be looked after as well when the usual day team isn't there and who is going to do that? You of course. But not worry it's not only you who is going to be on call. So basically your on call can be divided into two parts. Acute Take and Ward Cover.

Acute Take

Acute Take basically means taking referrals from A and E clerking them and deciding whether to admit or discharge them. The Acute Take team usually consists of a Consultant, Registrar, SHO(s) (Senior House Officer) to cover A and E and/or AMU and FY (Foundation Year) doctors and at some places PA (Physician Assistant) as well. The number of doctors varies from trust to trust. Some are very well staffed and some are very dependent on Locum to complete their numbers. SHO(s) may include trust grade doctors, CMT, ST doctors, MTI or CPSP (College of Physicians and Surgeons Pakistan) scholarship doctors.

A list of patients being referred by A and E is usually on your Trust system where you can access it. You pick up a patient go through the patients admission reasons, history, labs and examine and clerk the patient. Once you have done that ask the on call consultant to post Take the patient and decide about the admission. Then you pick up another patient and so on. Consultants aren't usually available on site overnight so you need to discuss them with your registrar. Consultant on call comes in the morning and conducts a Post Take Ward Round on all the patients admitted overnight.

Ward Cover

Now the acute take is pretty straight forward you keep clerking patients but ward cover is tricky and exhaustive depending upon the status of the staffing. Ward cover includes

• reviewing Sick patients that are NEWSing high (Read here about NEWS scoring), 

• MET calls (patients that are so sick that they are Pre-Arrest and require Medical Emergency Team involvement)

• Code Blue where patients have arrested and needs Resuscitation 
• Ward jobs, this is going to make the bulk of your day including everything from Bloods, ABGs, drug prescription, fluid prescription, to verifying death, speaking to family, reviewing images and of course doing cannula or catheterisation. 

Some trusts use a software called Nerve Centre which allows the staff to be interlinked uth and each. Suppose a nurse wants a patient to be reviewed she can put it on the Nerve Centre. The doctor covering wards carries a hand held device like an iPod which also has a Nerve Centre installed thus the doctor will be alerted. Thus if you are covering the ward you will have a list of jobs that you need to fulfill according to priority. There might be other doctors who are also doing ward cover or you could be the only one again depends on the the staffing. There is also a Registrar who covers the wards at times.

Duration and frequency of on calls 

Every trust differ slightly but generally there are

• Long days (Lights) : Usually 12 hr shifts, 08:00 - 20:30 or 09:00 - 21:30
• Nights : Again 12 hr shifts, 20:00 - 08:30 or 21:00 - 09:30
• Twilight : Now this one shift is an odd one which can be between 16:00 - 02:00 this may not be part of your regular on call rota 

The frequency of on calls depends on your contract and whether if you have opted out of maximum 48hr / week or not even if you have it won't be more than 56 hr / week. Roughly it ends up being one week of on calls every month or 2 weeks on on calls every 2 months. But discuss with your supervisor and Rota manager and you should be all set. And of course your pay scale will be according to your number of calls. CPSP scholarship doctors are on a fixed scholarship that includes on calls.

That was just a brief overview of the on calls work but every trust has its own ways of maximizing the outcomes from the on calls while making sure their doctors are content and well compensated.

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