ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS
IN RESPIRATORY CARE
On-Call Position Statement and
Recommendations for On-Call Service
Provision
April 2017
First published in 2017
By the Association of Chartered Physiotherapists in Respiratory Care
www.acprc.org.uk
Date for review: 2020
Procedure for reviewing the document: The ACPRC Committee will take on an
initial review of the document to determine whether an update is required.
Members will then be informed of this review at the AGM in 2020 for comment.
Any member can submit their feedback on the document at any time by emailing:
[email protected]
Reference this document as:
This document is available from the ACPRCs' website: www.acprc.org.uk
Acknowledgements
We would like to acknowledge that this paper has been written on behalf of the
ACPRC by the members of the on-call working group which comprises:
Sian Goddard
Lizzie Grillo
Ema Swingwood
With support of the 2017 ACPRC Committee
A special thank you to those attendees at the 2016 expert workshop organised to
consider the issues surrounding On-Call service provision in all areas of
respiratory Physiotherapy across the United Kingdom.
The consensus opinions of the workshop were collated and the following
recommendations for On-Call service provision were generated from this.
Explicit thanks is given to those who attending the workshop and were
instrumental in the recommendations, including Carley King, CSP Professional
Advisor. Thanks is also extended to the group who delivered the previous
ACPRC On Course for On Call Project, including MA Broad, Beverley Harden,
Matthew Quint and Sandy Thomas.
The Chartered Society of Physiotherapy have been involved in supporting and
reviewing this project and document, giving endorsement of its final content.
ACPRC Respiratory On-Call Position Statement
Introduction
On call services have been established within NHS services for decades. Such
services have been staffed by all grades and specialties of Chartered
Physiotherapists to provide acute and unplanned Assessment and Treatment of
adult and paediatric patients. Within such services there are often specific
arrangement for the frequency of on calls, different skill mix of staff and different
patient acuity depending on the local services and staffing structure. Moreover
the climate of the NHS has also led to some services being challenged, reduced or
removed in an effort to make financial savings or to minimize impact on staff. As
a result, numerous clinicians have come forward registering concerns and
questions about such services.
It is our vision that all trusts providing acute medical and surgical services
should ensure patient access to respiratory physiotherapy 24 hours a day, seven
days per week.
Purpose and Intention
The purpose of this document is to provide a comprehensive overview of the role
of respiratory physiotherapy on call services. This position paper formalises the
consensus of experts within the field of the issues surrounding on call and
provides clinicians and managers with a resource to support this important role.
It is intended that this document will generate discussion between
commissioners and service providers regarding the provision of on call services
to ensure that the service is of high quality.
This paper is a preliminary attempt to define and promote the role of on call
services as part of the management of patients in acute services. The working
group acknowledges that the document will have limitations, given that services
across the UK are diverse in terms of skill mix and patient dependency. However
this paper attempts to provide information to support the fundamental factors of
an on call service
.
Key recommendations
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All trusts providing acute medical and surgical services should ensure
patient access to respiratory physiotherapy 24 hours a day, seven days
per week.
The service must be staffed by qualified physiotherapists who are
competent to assess a respiratory patient and deliver the respiratory
interventions required.
Competence should be ensured through the practical maintenance of
clinical reasoning and clinical skills and not just through theoretical
updates.
An On Call service can be staffed by both respiratory physiotherapists and
non-respiratory physiotherapists as often it is not possible to maintain a
robust service without these staff members
Whilst the ACPRC appreciates the challenges of on-call duties to nonrespiratory staff we recommend that managers take appropriate action to
optimise training and support rather than to put a potentially life-saving
service at risk by reducing staffing numbers by not including such staff on
the rota
ACPRC recommends that all staff should undertake an on-call duty at least
once in a six week period ensuring that they complete at least 8 duties per
year
The ACPRC is clear that the key to maintaining a service and justifying its
worth is in collecting appropriate and meaningful data and in ensuring
that when on-call physiotherapy is provided, it is delivered in the most
effective way (see appendix on suggested data to be collected).
Compensatory rest is designed to ensure that staff who have worked
during the night and been deprived of sleep due to on-call duty, are not
placed in a situation where they are risking their safety or their decisionmaking due to fatigue. Managers have a responsibility to ensure that the
safety and wellbeing of both staff and patients (being treated by a physio
deprived of sleep) are paramount when designing their own
compensatory rest arrangements (see page 9 for further information).
ACPRC acknowledges the historical work completed within on-call
competency and training (eg: On Course for On Call). To complement this
a project to develop education resources to support general respiratory
competencies will be delivered over the next two years. ACPRC is happy
to provide advice and support to members about developing education
and competency for on call training
Definition of On Call
On-call systems exist as part of arrangements to provide appropriate service
cover for acute respiratory patients outside of core working hours.
A member of staff is on-call when, as part of an established arrangement with the
employer, the employee is available outside their normal working hours – either
at the workplace, at home or elsewhere – to work as and when required.
Position Statement
All trusts providing acute medical and surgical services should ensure patient
access to respiratory physiotherapy 24 hours a day, seven days per week. The
service will, by necessity, involve out of hours and night time working; however
the extent of this will be governed by the structure of the 'in hours' services e.g.
Seven day services or twilight services may reduce the on-call hours.
The service must be staffed by qualified physiotherapists who are competent to
assess a respiratory patient and deliver the respiratory interventions required.
Staff must be proficient in the use and operation of equipment that is used as an
adjunct to respiratory physiotherapy in that on-call environment. Competence
should be ensured through the practical maintenance of clinical reasoning and
clinical skills and not just through theoretical updates.
Patient safety and optimal patient outcome are the most important
considerations in service delivery. Moreover the health, safety and wellbeing of
the staff participating in this service should be considered in parallel, including
adequate time and facilities for rest alongside the appropriate financial reward,
and should form the basis of all service designs.
On-Call Service provision.
These recommendations are designed to assist senior Physiotherapists and
service managers in ensuring their On-Call service is fit-for-purpose and
supports staff and patients appropriately.
Non respiratory staff on the on-call rota
There are many benefits to non-respiratory staff working on the on-call rota;
these include:
 ensuring staff maintain a balance of acute v non acute work;
 maintains skills in current situation where patients generally are
becoming more complex;
 ensures all staff have skills to treat acutely unwell patients who may be
seen in any environment;
 provides evidence of broad skills so positive for the clinicians CV;
 good carryover with clinical reasoning into other clinical areas;
 offers training & CPD opportunities;
 sets a good example to more junior staff;
 good for MDT relationships;
 builds team working ethos within the Physiotherapy department if all
staff are on the rota;
 allows us to share the work of our professions and the benefits of our
role;
 keeping senior staff on call increases option for training.
ACPRC recognises that individual staff may feel strongly that they should not be a
part of the On-Call rota. In the majority of cases this is the result of a lack of
confidence or training; or a lack of understanding of the importance of
maintaining an on-call service with appropriate staff base to prevent burn out of
a small number of highly skilled staff.
Whilst the ACPRC appreciates the challenges of on-call duties to non-respiratory
staff we recommend that if it is not possible to maintain a robust service without
these staff members, then the appropriate action is to improve training and
support rather than to put a potentially life-saving service at risk by reducing
staffing numbers. (Please refer to recommendations on training.)
ACPRC recommend that an on-call rota should have a minimum of 15 staff at any
one time which would mean staff perform no more than three overnight duties
per month allowing for leave and sickness.
Part time staff
Some Trusts do not include part time staff less than 0.5WTE due to the
maintenance of competencies, time to be released etc.
ACPRC recommend that if the part time staff member is based in a respiratory
environment or acute ward environment then they should be included in the oncall rota on a pro-rata basis as a minimum requirement. (Some trusts may
include these staff on the rota in the same ratio as staff on greater hours). If the
part time staff member is not based in an acute ward or respiratory environment
then the time requirement to maintain skills appropriate to the on-call role may
impact significantly on their hours in their core role. Such situations should be
considered by their line manager on a individual basis to decide if the staff
member can carry out their core role alongside adequate training required for on
call. Staff returning to work part time following maternity leave should be
reminded that an application for part time working should also consider the
impact of part time working on any previous on-call role.
Minimal frequency of on call duties
ACPRC recommends that all staff should undertake an on-call duty at least once
in a six week period ensuring that they complete at least 8 duties per year. This
should be same for all staff on an on-call rota.
Senior staff participating in On-Call
ACPRC recommend that senior grades of respiratory staff (Band 7 and Band 8a)
should participate in the on-call rota (on a pro-rata basis if necessary) despite
this perhaps meaning they carry out on-call duties at a pay band lower than their
substantive rate. This recommendation is already carried out by the majority of
departments and it is the belief of the ACPRC that this promotes the value of an
on call service to junior staff and ensures the rota has both experienced and
junior staff.
Withdrawing an on-call service
ACPRC are aware of trusts that have considered the withdrawal of their on-call
service. ACPRC feel strongly that this could potentially cause harm to acute
respiratory patients who would therefore not receive essential acute respiratory
assessment and/or input.
Of these trust, ACPRC are aware that few have carried out this process and some
of those who did withdraw services have since reinstated them.
ACPRC is clear that they key to maintaining a service and justifying its worth is in
collecting appropriate and meaningful data and in ensuring that when on-call
physiotherapy is provided, it is delivered in the most effective way (see
recommendations below).
Be prepared to consider changes to your service, such as withdrawal from less
acute sites or introduction of a twilight service.
In general, physiotherapy on-call services are less costly than many other models
of hospital on-call service provision and this will work in your favour during
negotiations.
The following recommendations will be of assistance:
Data Collection
 ACPRC advises that service managers collect callout data continuously.
However, if this is not normal practice, you should ensure all calls are
carefully logged for a six to twelve month period to take account of
changes in demand with seasons. This log will allow you to justify the oncall provision based on patient outcomes, identify any patterns of on-call
referrals and to highlight potential for changes in service provision such
as a twilight service. (See the example log in Appendices)
This log should state:
-times of calls
-who made the referral
-reason for call out (statement of the potential harm the patient was a risk
of)
-Information was given to physio by referrer
-The decision by the physiotherapist to attend/not attend
-Outcome of assessment by physiotherapist
-Intervention given, including phone advice if relevant (see example log in
Appendices).
Understanding of reason for change in service provision
 Understand the drive for challenging the on-call service. Is it financial or
is it a workforce issue or is the existing service understaffed? This will
trigger the focus of your response and ensure your business case appeals
to the management issues. Never underestimate the value of the quality
agenda and the cost, both financial and legal, of poor patient outcomes
associated with the withdrawal of a relatively inexpensive service.
 Involve your stakeholders in justifying your service – discuss with
consultants, obtain patient or relatives accounts of the benefits on on-call
physiotherapy and document or incident report any situation where oncall physiotherapy was not involved and could have made a difference.
 Revisit your on-call policy and ensure it is robust. It should clearly state
what profession and grade of staff may activate an on-call referral (this
may differ for specialist wards where a nurse may be appropriate).
 Carry out training with all new starter ward doctors to ensure they are
aware of the on-call service and detail what situations and conditions
would be appropriate for emergency respiratory physiotherapy, and
which would be inappropriate.
 Ensure your on-call training for physiotherapy staff is robust and that all
staff feel empowered to adhere to policy guidelines on inappropriate
referrers and inappropriate referral conditions. Consider introducing a
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buddy system to support less confident staff in refusing on-call referrals if
the situations arises.
Investigate directorate specific funding if your on-call log demonstrates
high callouts to specialist areas (such as paediatrics, neonatal unit or
critical care.
Publicise widely what the benefits of physiotherapy are and what on-call
physiotherapy can offer that nursing staff are not able to offer.
Compensatory Rest
The legal obligation is defined by the Working Time Regulations (WTR)
1998, Regulation 10 (i) of which states : An adult worker is entitled to a rest
period of not less than eleven consecutive hours in each 24-hour period during
which he works for his employer.
ACPRC recognises that this is a contentious and challenging issue to resolve and
will ultimately be determined by local negotiation. It is essential to ensure your
local CSP steward is involved and uses the advice and input of the CSP regional
officer to assist in negotiating the best possible deal for staff.
Compensatory rest is designed to ensure that staff who have worked during the
night and been deprived of sleep due to on-call duty, are not placed in a situation
where they are risking their safety or their decision-making due to fatigue. If
compensatory rest is not paid time, then staff are understandably reluctant to
take this time, however the safety of patients should be of paramount
importance.
It is important to acknowledge that if staff are given compensatory rest (time off
during working hours) for on-call duties then they are being paid twice if they
are also paid for their on-call duty time. Trusts have the right to offer pay or
compensatory rest and not both. In addition to this, electronic staff records may
prevent staff from being formally given compensatory rest and pay for on-call
duty as some systems would not allow both to be registered.
Solutions to this are as follows:
 Some trusts have added a percentage to annual pay to allow for
compensatory rest
 Compensatory rest can be given unofficially and not recorded.
 Most trusts who have implemented compensatory rest have offered a
graduated system where the amount of compensatory rest is based upon
the time of the call-out (see examples in attached document).
Guidance for on call training.
A separate ACPRC project on education in respiratory physiotherapy will be
available from Autumn 2018, but the following guidance is designed to assist
service providers in ensuring the appropriate levels of training are in place.
How can we demonstrate competency in our staff?
Competency should be assessed by the individual staff member since all
Chartered Physiotherapists are autonomous practitioners and are therefore
responsible for ensuring they maintain their competence for practice in the areas
in which they work. This includes on-call if that is within the job description.
ACPRC recommend that all physiotherapists participating in an on-call rota carry
out a self-assessment form. (The ACPRC have produced a self assessment form
to aid this process – ACPRC Self-evaluation Questionnaire 2017).
This will enable staff to identify areas where they are less confident, as well as
areas where they feel they lack competence (or are observed as lacking
competence). This should be done at least annually and be used to direct
training and ensure that all competencies are achieved and refreshed annually.
It is not always possible to ensure that all areas where there is a lack of
confidence are addressed but this is the responsibility of the staff member to
ensure they arrange additional training or ward based experience in order to
improve confidence.
What training is required to maintain skills?
This will be specific to each Trust and hospital. All physiotherapists participating
in an on call rota should maintain their skills in respiratory assessment,
positioning, manual techniques and basic airway clearance techniques such as
ACBT.
Other competencies such as Autogenic drainage, suction, manual hyperinflation,
IPPB, Manual Insufflation/Exsufflation will be required if these treatments are
delivered in the hospital setting where the staff member is employed.
Each hospital should have a list of competencies appropriate to their setting.
How often should training be provided and how much should I do?
ACPRC recommend that as a minimum an annual update of on-call training
should be provided. For those staff not working in an acute or respiratory
environment regularly, or for those who have identified competence or
confidence issues, training may be required more frequently.
It is recommended that a mix of theory and practical sessions be used in on-call
training to ensure that handling skills, practical application of techniques, and
positioning are practiced in addition to updating theoretical knowledge.
Frequently asked Questions.
ACPRC appreciate the challenges of on-call working for those who are not
normally based in a respiratory setting. We have tried to answer some of the
questions which are frequently posed by non-respiratory on-call staff.
I don’t work in a respiratory setting; surely the nurses on the ward can do
more than I could?
Nursing staff are not trained to be physiotherapists and do not have the same
skills in respiratory assessment, positioning and the anatomical/physiological
knowledge of airway clearance mechanisms that physiotherapists have gained
through their training. Even staff who do not work in this speciality still have
those inherent skills of assessment and knowledge underpinning their general
practice. It is these skills which set physiotherapists apart from a nurse working
in a respiratory setting. Although skills in some treatment techniques may not
be at an expert level, they will still be more appropriately used by a
physiotherapist combining this with assessment, clinical reasoning and
positioning.
It is important that all physiotherapists protect the skills of their profession,
whatever field they are working in.
I do not feel I am very effective as an on-call Physiotherapist.
The aim of an on-call service is to provide out of hours respiratory physiotherapy
to patients who will deteriorate if not seen before the next working day. There is
no requirement for all staff to provide expert treatment and there will be no
expectation that non-respiratory staff would work at this level. However, as
stated before, all Physiotherapists will be able to assess, reason and treat
appropriately and effectively, using clinical reasoning with underpinning
anatomical and physiological knowledge which other healthcare professionals
do not possess.
ACPRC recommend that any member of on-call staff who does not feel they are
working effectively should carry out the self-evaluation of competence
questionnaire (ACPRC, 2017) and request further training.
Surely the on call work should be carried out by respiratory
physiotherapists?
In most hospitals it is not possible for the respiratory on call rota to be covered
by the respiratory staff alone and therefore it is simply not an option to expect
these staff to work all the out of hours duties.
When considering whether static musculoskeletal Physiotherapy staff should
participate in on-call duties, there is a large variation between NHS Trusts. With
appropriate training in place, there is no reason these staff should not be able to
maintain competence. ACPRC recommend that rotational staff in
musculoskeletal roles should participate in on-call duties in order to maintain
competence; however, it may be appropriate to ensure on-call duties are
arranged to fit in with planned gaps in clinic appointments to ensure
compensatory rest is possible and ensure the service is not affected.