Career Story: Cross-trust working

Extending one’s tentacles outside the employing trust would normally start with tactful inquiry to your (hopefully open-minded) line manager. Such an arrangement is easier to square if there is an obvious mutual benefit to the trust in terms of either bringing back externallygained expertise or building relations between centres. This isn’t necessarily a key advantage of my arrangement, but obstetric medicine, cardiac anaesthesia, and long term weaning (for example) are addons that would understandably be viewed positively. 

Flexibility 

I started as an ICU consultant in 2018 and added in lung transplant medicine when an opportunity arose a year later. Getting the arrangement off the ground was ultimately testament to the flexibility of the two respective departments/clinical leads, and was achieved after a few weeks of amicable negotiations. An overly demanding approach never seems to help these conversations, and recognising the duty to contribute to both departments over and above the usual direct clinical care is helpful. As an example, I have clinical lead roles for morbidity and mortality in the ICU and organ utilisation (albeit NHSBT-funded) in the transplant department. Teaching, quality improvement work and clinical time is also equally divided. 

On-call commitment 

Competing needs for weekend cover can be a stumbling block with structuring a bespoke rota; though if there is sufficient flex for weekends to be allocated, pro rata between the specialties, this might not materially alter the weekend frequency. Yes, it may affect the on-call supplement by shifting up or down a category, but the effect on pay is usually marginal.  For medical specialties in particular, where there are outpatient responsibilities in addition to inpatient work, then redundancy and CNS support are extremely advantageous. Cross cover with another consultant colleague allows clinics to continue seamlessly in the face of interruptions for ICU work or leave, and clinical nurse specialists are invaluable in providing clinical admin support. 

Contracts 

The contractual status can be arranged in a number of ways. Ad hoc locum shifts at the second workplace may be flexible and financially advantageous, but not provide the desired level of long-term security. 

Many clinical academics have had a memorandum of understanding, mainly with the academic institution as the principle employer. Two part time contracts via competitive appointment may be laborious to achieve and add complexity to tax (two p60s per year!) and pensions — a route I was heavily dissuaded from taking, primarily to avoid a complicated tax return! 

A service level agreement (SLA), appears to offer a reasonable solution, whereby Trust A is fully responsible for salary, but bills Trust B proportionally for the number of PAs taken via the SLA, whilst also building in a notice period of mutually agreed length and equivalent employer responsibilities, except for appraisal and revalidation which are not duplicated. This works well for me, though many intensivists reach happy agreements with external employers for their split roles (transfer services, HEMS etc) using any of these frameworks. 

Job satisfaction 

Flexibility is becoming a core aspect of job satisfaction, and employers and clinical leads appear increasingly amenable to making such arrangements possible, so if you have cross-site working in mind, don’t hesitate to ask around. Good luck!