Overcoming taxing issues with taxis | Association of Anaesthetists

Overcoming taxing issues with taxis

Overcoming taxing issues with taxis

Most anaesthetists at some point in their career will have found themselves after a transfer stood outside an unfamiliar hospital, in the cold, with a mountain of equipment waiting for a taxi to take them back to their usual place of work. The inter-hospital transfer of critically ill patients more often than not falls to trainees. Some critical care networks have developed dedicated transfer services with a specialist transfer team or trolley. This means the ambulance service is obliged to transport the clinical team back to their base hospital. However, in London the demands on the London Ambulance Service mean this return journey is not possible, no matter how hard an anaesthetist might try to charm the paramedics.

The Association’s 2009 Interhospital Transfer safety guideline states ‘arrangements must be in place to ensure that personnel and equipment can safely and promptly return to base after the transfer’ [1]. At our Trust we audited against these guidelines and found 80% of trainees had experienced significant delays, with several waiting up to three hours for a taxi. As these staff were usually part of the on-call team there were important repercussions for the hospital as well as great frustration for the trainees. ‘CEPOD cases’ were being delayed, cover for emergencies such as cardiac arrests were reduced and, in some cases, daytime elective lists were being cancelled when the oncall consultant had been called in overnight.

The issue it seemed was twofold. Firstly, there were delays just booking a taxi through the Trust’s contracted taxi firm. The convoluted process involved the transfer team calling the intensive care nurse in charge, who then spoke with the site manager. The site manager had to sign an authorisation form which was then faxed to hospital security. Hospital security then contacted the taxi booking office to arrange the pick-up. The second issue was that the taxi firm the Trust used frequently did not have taxis regularly available in the vicinity of the hospitals where they were needed. At night sometimes just a single taxi driver would be covering the whole network’s activity.

The solution seemed clear to all front-line clinicians. London is not short of taxis. In recent years firms such as Addison Lee and Uber have firmly established themselves across the city, with many more vehicles and far greater coverage than the Trust’s taxi firm. When compared with the contracted taxi firm’s rates, use of the former was relatively cost neutral, whereas the latter would provide the Trust with a potential cost saving benefit. Trainees could order a taxi using their smart phone and submit their receipt later and claim back the expenses. Several trusts in London already have accounts with these providers. The London Ambulance Service even uses them to transfer patients.

This project quickly gained the backing of the clinical leads and the departmental service manager. However, the Trust’s management team were less enthusiastic. Objections were wide ranging. One particularly notable objection was that the Trust couldn’t guarantee that other taxi drivers would be trained in safeguarding, moving and handling, or looking after passengers with dementia. Since we were only ever proposing the use of these taxis for staff transport, this did raise some eyebrows. Other objections were more reasoned, for example the insurance arrangements for the equipment that was to be carried.

Potential barriers addressed

The difficulty we encountered was identifying ultimately who had the authority to approve this project. Identifying the hierarchy and management structure was challenging. Emails bounced back and forth between senior managers in the finance, contracts and estates departments, often with very lengthy intervals between replies. There did not seem to be a great deal of interest for the project, nor, as was becoming clear, much understanding about the clinical need either. After several months with little progress, we attended a feedback meeting with the Trust’s taxi firm. Getting the various stakeholders in a room together for a meeting achieved far more than months of back-and-forth emails. It meant the project and its motivations could be clearly articulated and the potential barriers addressed.

The Trust’s legal team had a number of concerns, ranging from personal liability cover to licensing and criminal record check issues. These are all covered by a Transport for London government license, but it took time to investigate. One of the greatest issues to resolve was whether the Trust’s equipment would be insured in the event of an accident. Once it became clear that it wasn’t, we made further inquiries. It transpired that it also wasn’t covered when using the Trust’s contracted taxi firm, and potentially not even when travelling with the ambulance service. We had done a great deal of research into the various legal arguments but couldn’t find a member of senior management to hear our case. Momentum faltered and it seemed like the project was doomed. At this point we decided to escalate the issue to the Chief Executive. In a thorough but concise email we explained the background to the project and our proposed solution. In less than 24 hours we had a reply explaining that he had made the necessary enquiries and the project had been approved. Trainees would be allowed to use Uber taxis to get back to work after their transfers.

This quality improvement project took over 18 months to implement. Due to the project’s nature, most of the work was done with the departmental service manager rather than through a lead consultant. This was perhaps different to many other quality improvement projects trainees may be involved with. These issues are not unique to London. We hope that others consider implementing such a system at their place of work. We are very happy to share specific learning or answer questions others may have.

Chris King
ST4 Anaesthetist
Lewisham and Greenwich NHS Trust

Key learning points:

  • Consider involving your departmental service manager in quality improvement work. Their support can be invaluable. Try to meet them and other stakeholders face-to-face. More can often be achieved through a meeting than many back-and-forth emails. 
  • Be persistent. Don’t give up at the first hurdle. Where objections are made, try and relate back to the implications they may have for patient care. 
  • When all else fails, escalate (appropriately). Contacting the Chief Executive seemed like a bold move at the time but achieved more in 24 hours than the previous three months of work.