You will be required to balance both outpatients' and inpatients' demands, taking into account government targets. How will you go about this?

Describe how you would manage the diverse demands on the service, given the resource available to you.

This is essentially about setting a budget and managing it.

Setting a budget - this depends on forecasting the numbers of patients, patient days and nursing resources needed, other costs of supplies and personnel etc. Decisions on setting the budget should be based on reality and real trends rather than historical data.

The process of managing the budget can be broken down into four stages:

1. Establish actual position - In general, the budget can be divided into monthly blocks. It is important to focus on the future position to control the budget. The calculation of the out-turn (amount of spend to date/number of months to date X12 equals projected out-turn) formula will provide the year-end position for pay and non-pay expenditure.

2. Compare actual expenditure with budget totals - this will indicate whether the budget is over- or underspent and help you to identify the spending pattern. For example, use of bank and agency staff will create potential overspending, thus careful monitoring is essential.

3. Establish reasons for variance - Variance is the difference between the budgeted amount for the month and the actual amount spent. The reasons for variance must be sought. It could be due to an anticipated increase or decrease in workload and therefore be of no particular concern. However, variance may be completely unexpected, and in such cases the reasons must be found.

4. Take action - Variance could be due to mistakes. Items may have been wrongly attributed to a budget or miscoded and end up in the wrong division of the budget. These problems can be corrected with the help of the finance manager. The budget must be checked for every transaction and corrected where necessary.

How will you spend 50 K on service improvement in the department?

Your pre-interview visit will give you a good insight as to the need for new services or any improvement needed in the services provided. Discuss the need for the service, the benefits it will bring (try and marry it to NICE guidance, waiting targets or Trust’s strategic direction, if possible) and the costs involved (i.e. 50 K). Don’t forget to mention that you will talk to all stakeholders, so that they have ownership of the service. Also need to mention clinical governance issues (i.e. regular audit to ensure that the service is meeting expectations).

Tell me about changes in practice that you have helped to initiate in your posts so far.

Discuss any changes you made in your training post. Most changes usually happen as a result of audits. Discuss your experience of change management - for example, talking to colleagues, bringing a difficult person on board, arriving at a consensus etc. Discuss also how the change was implemented and how it led to improved services.
You may also discuss any hospital guidelines authored by you or changes to the rota initiated by yourself.

Change management

RAID - 4-step process-

R - Review - where are we now? Gathering information, listening to patients and staff, looking at audit, documentation and process

A - Agree - gain consensus, build teams, formulate recommendations, shape the future

I - Intervene - project management, priorities, dealing with transition, motivate and support staff, expect and deal with resistance

D - Demonstrate - project analysis, show the differences, identify lessons, plan next objectives

Tell me how you would bring this new technique into the trust?

You may be required to set up services not presently in existence; how would you go about this?

How will you make sure that patients play a part in the set up of the service?

The steps to setting up a new service/technique are:

Defining the need -

• Why are new services needed? Will the service alleviate a significant risk to the trust? Will the service help the trust and/or PCT meet government targets? Does the service fit in with the trusts strategic direction?

Demand and capacity theory is at the forefront of a lot of modernisation work. You will need to demonstrate that the demand on your service exceeds its capacity, whether that is staff, buildings or equipment. Activity data is a powerful tool and most trusts will have an information team which would be able to provide you with a range of activity information linked to you or your service.

• Costs and benefits of the services

• Costs - assess the resources required, including staff. You will need to discuss the funding with potential sponsors. Sponsors could be your own trust or the PCT.

• What type of funding might I access?

• There are two types of funding: revenue (this funding is added to your budget year on year; for example, staff salaries have a revenue implication) and capital (this funding is a one-off resource allocation and is usually linked to equipment or buildings).

• Where would the funding come from?

• Trust Capital, PCT or SHA. Various incentive schemes - can provide useful funding opportunities. This type of scheme will usually have a proforma which will tell you the information that will be considered in the bidding process - it will also be explicit in what it requires to be delivered in return for the investment, particularly around waiting times and access.

• Write up a business case - stating basically the need for the services (detail your research) and the cost and benefits of the services. Be clear about both costs and benefits for your department, the organisation, and the wider community, and include immediate, short- and long-term implications. It is often the financial implications of proposals that carry the most weight and so make the financial case for the changes you are proposing as powerfully as possible.

• Your service or general manager will help you write up the business case. They are there to support you in delivering your clinical service. The service manager and/or a member of the financial team can help convert your ideas into the required business case.

• Implementation - implement the changes gradually with strict monitoring. Audit the service to ensure that the objectives set in the business plan are achieved.

Public and patient involvement is vital in the development and improvement of any services. Services need to be responsive to the needs of the patients and public, as they are end users of all services. I would ensure patients' involvement in services by involving the public and patient forum, as well as regular patient surveys.

Case Study 1 - The clinical nurse specialist

Problem: busy clinics, long waiting list and perhaps an NSF requirement

Solution: introduction of a clinical nurse specialist to work alongside consultant teams in
clinic and undertake a telephone follow-up clinic.

In your business case, you will need to:

• Establish the case for need

• Provide an analysis of current and predicted demand

• Assess how the proposal will resolve future service demands (activity flow changes, operational policy changes)

• Estimate costs of the proposal - capital or revenue - e.g. salary, equipment, accommodation etc.

• Provide the associated support costs - e.g. perhaps an increase in diagnostics.

Case Study 2 - Medical equipment

Problem: equipment at the end of its asset life and/or opportunities for advances in
equipment to support service provision

Solution: replacement of equipment with a revised specification.

In your business case you will need to:

• Establish the case for need

• Provide options for purchase, including changes in practice and operational requirements

• Cost assessment - total purchase or lease, consumable costs, staff changes and maintenance requirements

• Clinical risk assessment and quality advantages

• The implications of ‘do nothing’.

A major incident occurs and you are the consultant on call. How do you handle it?

You are the consultant in casualty. A police officer informs you on a weekend that there are 100 casualties in a football ground. How will you deal with it?

I would promptly assess the situation and discuss the situation with the clinical/medical director or chief executive and initiate the major incident policy of the trust. Every trust has a major incident policy.

A major incident is any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or primary care organisations.

What is a major incident plan?

• To describe how the Trust operates in the event of a major incident (internal or external)

• To assist staff, by providing a framework for action, specific instructions and resources

• To ensure that incident responses are structured, coordinated and managed effectively from the outset

• To enable the Trust’s response to be coordinated with others

• To ensure appropriate communication channels

• To enable the effectiveness of actions to be evaluated.

Ref-

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_5441600

Publications/PublicationsPolicyAndGuidance/Browsable/DH_5441600

Staff morale can sometimes be low - what do you intend to do to help this?

• Treating them as human beings

• Valuing their contribution

• Feedback

• Involving them in decision making

• Understanding their aspirations

• Providing effective leadership

Give an example of where you’ve prioritised clinical need.

As registrars on call, we all prioritise clinical needs. Mention any particularly busy on-call and tell them how you marshalled your team to manage the team effectively:

• Requested the charge nurse to triage the patients
• Minor cases allocated to junior members
• Serious cases seen by SHO with my support
• Kept my consultant informed
• Gave regular feedback to the team members

What is your take on litigation?

Well, I am a good doctor. But I expect to be involved in litigation because it is likely to happen - as it comes with the territory because of the complexity of the cases and interpersonal relationships.

You are the consultant on call. You have been informed that an inpatient with varices is re-bleeding and there have been two admissions in the last few minutes with complete heart block and respiratory failure needing BiPAP. The registrar is panicking. What do you do?

Clinical scenarios are common at interviews; however, at consultant interview the focus is not on clinical steps, but towards people management and governance.
The answer needs to show how the candidate would take charge there and then, but also that he knows that the problem does not end there. He has to take reasonable steps to prevent the recurrence of the situation.
It would be better for the consultant to say that he would form a plan with his registrar and phone his consultant colleagues. So, for example, a plan may be that he seeks anaesthetic help to deal with the respiratory failure. Ask the SHO to start an isoprenaline drip and the registrar to deal with the bleed with an SB tube as needed or call in GI colleagues if available. You will need to go in and help out.
The consultant should debrief the juniors, discuss what has happened with the clinical director, and discuss it in the clinical governance meeting.

What is your opinion of a sub-consultant grade?