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’ . 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.
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.