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<strong>Consultant</strong> <strong>physicians</strong><strong>working</strong> <strong>with</strong> <strong>patients</strong>The duties, responsibilities andpractice <strong>of</strong> <strong>physicians</strong> in medicineRevised 5th edition 2013 (online update)


<strong>Consultant</strong> <strong>physicians</strong><strong>working</strong> <strong>with</strong> <strong>patients</strong>The duties, responsibilities andpractice <strong>of</strong> <strong>physicians</strong> in medicineRevised 5th edition 2013 (online update)1 Physicians in the NHS today2 The work <strong>of</strong> the specialties3 The <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians:supporting the delivery <strong>of</strong> high-quality care


The <strong>Royal</strong> <strong>College</strong> <strong>of</strong> PhysiciansThe <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians plays a leading role in the delivery <strong>of</strong> high-quality patient care by settingstandards <strong>of</strong> medical practice and promoting clinical excellence. We provide <strong>physicians</strong> in over 30 medicalspecialties <strong>with</strong> education, training and support throughout their careers. As an independent charityrepresenting more than 28,000 fellows and members worldwide, we advise and work <strong>with</strong> government,<strong>patients</strong>, allied healthcare pr<strong>of</strong>essionals and the public to improve health and healthcare.Citation for this document: <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. <strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>, revised 5thedition (online update). London: RCP, 2013.Review date: 2015Production TeamEditorLinda Patterson OBEProject manager Urooj Asif AkhtarCopyrightAll rights reserved. No part <strong>of</strong> this publication may be reproduced in any form (including photocopying orstoring it in any medium by electronic means and whether or not transiently or incidentally to some other use<strong>of</strong> this publication) <strong>with</strong>out the written permission <strong>of</strong> the copyright owner. Applications for the copyrightowner’s written permission to reproduce any part <strong>of</strong> this publication should be addressed to the publisher.Copyright C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013eISBN 978-1-86016-512-2<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians11 St Andrews PlaceRegent’s ParkLondon NW1 4LEwww.rcplondon.ac.ukRegistered Charity No 210508Typeset by Aptara Inc., India


ContentsAcknowledgementsForewordAbbreviationsivvvi1 Physicians in the NHS today 12 The work <strong>of</strong> the specialties 15Acute internal medicine and general internal medicine 17Allergy 27Audiovestibular medicine 35Cardiovascular medicine and paediatric cardiology<strong>with</strong> adult congenital cardiology 47Clinical genetics 59Clinical neurophysiology 67Clinical pharmacology and therapeutics 73Dermatology 81Diabetes and endocrinology 91Gastroenterology and hepatology 99Genitourinary medicine 111Geriatric medicine 119Haematology 127Immunology 137Infectious diseases and tropical medicine 145Medical oncology 153Medical ophthalmology 161Metabolic medicine 167Neurology 173Nuclear medicine 181Palliative medicine 189Pharmaceutical medicine 199Rehabilitation medicine 205Renal medicine 213Respiratory medicine 225Rheumatology 235Sport and exercise medicine 251Stroke medicine 2553 The <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians: supporting the delivery <strong>of</strong> high-quality care 263C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013iii


AcknowledgementsWe would like to thank the following people who gave freely <strong>of</strong> their time and expertise. Their contributions tothis edition were greatly valued.Sir Richard Thompson PresidentDr Patrick Cadigan RegistrarPr<strong>of</strong>essor Tim Evans Former academic vice-presidentDr Andrew Goddard Director, Medical Workforce UnitDr Ian Starke Clinical director <strong>of</strong> revalidationJane Ingham Director, Clinical StandardsDr Kevin Stewart Director, Clinical Effectiveness and Evaluation UnitDr Ian Mungall Director, Invited Service ReviewsPr<strong>of</strong>essor John Williams Clinical director, Health Informatics UnitWinnie Wade Director, Education DepartmentPr<strong>of</strong>essor David Worrell Director, International OfficePr<strong>of</strong>essor Bill Burr Medical director, Joint <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians Training BoardJoanna Reid Managing editor, Corporate Communications and Publishing teamiv C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


ForewordThe revised fifth edition <strong>of</strong> <strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> is more relevant than ever, as it coincides<strong>with</strong> the major change in commissioning arrangements in England. I hope that the information containedhere on service organisation and standards, workload, job plans and the role <strong>of</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physiciansin supporting these activities will also be <strong>of</strong> particular value to clinical commissioning groups as they take uptheir new role.To support the commissioning process, the RCP has developed a clinical commissioning hub on its website,containing all the elements <strong>of</strong> its work that can contribute to commissioning decisions – clinical guidelines,audit results, quality improvement programmes, and information relating to all 30 medical specialties coveredby the RCP. Each specialty chapter <strong>of</strong> this book contains major recommendations specifically forcommissioners. Further information on the role <strong>of</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians and the clinicalcommissioning hub can be found on our website (www.rcplondon.ac.uk). This information is also relevant tothe planning processes in the devolved nations.<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> will also help individual <strong>physicians</strong> and clinical teams demonstratehow the structures and resources described here will result in high-quality patient care, which is vital at a timewhen the NHS faces major financial constraints. We underline the importance <strong>of</strong> multidisciplinary team<strong>working</strong>, not just <strong>with</strong>in the hospital, but stretching out across primary, community and social care, to supportintegrated care for <strong>patients</strong> and bring care ‘closer to home’.I am enormously grateful to all those who have contributed, and in particular to our clinical vice-presidentDr Linda Patterson OBE, and to Urooj Akhtar, who has quietly and efficiently put it all together.June 2013Sir Richard ThompsonPresident, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> PhysiciansC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013v


AbbreviationsA&EAACsAMUsARCPCCGsCCSTCCTCEEUCESRCMOCMTCPDCQCDFIDDGHDHDOPSEWTDGIMGMCGPwSIGSFHDUHESHIUHPAHWDUICUsIOGJRCPTBaccident and emergencyAdvisory Appointment Committeesacute medicine unitsAnnual Review <strong>of</strong> CompetenceProgressionclinical commissioning groupsCertificate <strong>of</strong> Completion <strong>of</strong> SpecialistTrainingCertificate <strong>of</strong> Completion <strong>of</strong> TrainingClinical Effectiveness and EvaluationUnitCertificates <strong>of</strong> Eligibility for SpecialistRegistrationchief medical <strong>of</strong>ficerCore Medical Trainingcontinuing pr<strong>of</strong>essional developmentCare Quality CommissionDepartment for InternationalDevelopmentdistrict general hospitalDepartment <strong>of</strong> Healthdirectly observed procedural skillsEuropean Working Time Directivegeneral internal medicineGeneral Medical Councilgeneral practitioner <strong>with</strong> a specialinterestGold Standards Frameworkhigh dependency unitHospital Episode StatisticsHealth Informatics UnitHealth Protection AgencyHealth and Work Development Unitintensive care unitsImproving Outcomes GuidanceJoint <strong>Royal</strong> <strong>College</strong> <strong>of</strong> PhysiciansTraining BoardKBALATMAUMDTMINAPmini-CEXMMCMRCMTASNCGCNHDsNHSNICENSFsNTNOoHMTPAsPACESPbRPCNPGDsPIUPMETBPwSIsRITASACSASSPAsStRWHOWTEknowledge-based assessmentlocum appointment for trainingmedical admissions unitmultidisciplinary teamMyocardial Infarction Audit Projectmini clinical evaluation exerciseModernising Medical CareersMedical Research CouncilMedical Training Application ServiceNational Clinical Guideline Centrenotional half daysNational Health ServiceNational Institute for Health and CareExcellenceNational Service Frameworksnational training numbersOut-<strong>of</strong>-Hours Medical Teamprogrammed activitiesPractical Assessment <strong>of</strong> ClinicalExamination SkillsPayment by ResultsPatient and Carer Networkpatient group directionsPatient Involvement UnitPostgraduate Medical Education andTraining Boardpractitioners <strong>with</strong> a special interestRecord <strong>of</strong> In-Training Assessmentspecialist advisory committeestaff and associate specialistssupporting pr<strong>of</strong>essional activitiesspecialty registrarWorld Health Organizationwhole-time equivalentNote: this edition uses the terminology specialty registrar (StR) to update the term specialist registrar (SpR).vi C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>in the UK is ageing. Citizens want to be more involvedin decisions about their care and make greater demandsfor more personalised care. Scientific and technologicaladvances are moving rapidly, but healthcare has to besupported by the economic wealth <strong>of</strong> the country, <strong>with</strong>a need for more co-management <strong>of</strong> health by <strong>patients</strong>and self-reliance if the costs are not going to overwhelmthe national budget. This scenario was well described byWanless in his report. 4 Social trends <strong>of</strong> increasingobesity and excess alcohol consumption, along <strong>with</strong>rising chronic disease in the population, are provingchallenging, and health inequalities between differentsections <strong>of</strong> the population and in different localitiesneed to be tackled. 5 The Marmot report calls on themedical pr<strong>of</strong>ession to lead on all these issues, <strong>with</strong>leadership based on the values <strong>of</strong> pr<strong>of</strong>essionalism,<strong>working</strong> in partnership <strong>with</strong> others. 5In 2013, Robert Francis published his report on the MidStaffordshire NHS Foundation Trust public enquiry.The RCP was an invited participant in the enquiry. Thefindings, <strong>of</strong> a need for an overall cultural change toreally put <strong>patients</strong> at the heart <strong>of</strong> care and to ensure thatthey are always treated <strong>with</strong> dignity and kindness is achallenge to all parts <strong>of</strong> the system. The RCP will belooking at all the recommendations and restating ourcommitment to clinical leadership at the bedside,based on pr<strong>of</strong>essionalism and also wider engagement<strong>with</strong> the system to ensure that quality <strong>of</strong> care is alwaysput first. 6 See the RCP website (www.rcplondon.ac.uk)for the RCP’s response to the Francis Inquiry report.Quality improvementThe quality spiral shows how the RCP sets standardsand encourages <strong>physicians</strong> to measure against thosestandards, to undertake improvement by implementingchange and then to go on improving.There is a programme <strong>of</strong> work at the RCP that has beendeveloped to encourage and support <strong>physicians</strong> toevaluate and improve their clinical practice and henceimprove patient care. Physicians are able to draw onresources from the RCP at all stages <strong>of</strong> the ‘qualityspiral’ (Fig 1). The RCP has published its qualitystrategy to direct the quality improvement work <strong>of</strong> theRCP. 7 It describes quality in seven domains:1 safety2 patient experience3 effectiveness4 equityFig 1 The RCP quality spiral.5 efficiency6 timeliness7 sustainability.The quality improvement work <strong>of</strong> the RCP is organisedto support improvements in all these domains whichunderpins the pr<strong>of</strong>essional practice <strong>of</strong> doctors. The RCPsupports fellows and members, and the organisationsand teams in which they work, to improve the quality<strong>of</strong> clinical care that they deliver to <strong>patients</strong> by: medicaltraining and examinations; education and trainingprogrammes; developing clinical guidelines; conductingnational comparative audits; quality improvementprojects, facilitating data and informaticsimprovements; undertaking invited service reviews;and supporting members preparing for appraisal andrevalidation.The production <strong>of</strong> clinical guidelines and best practiceby the RCP is supplemented by the work <strong>of</strong> specialistsocieties who work on additional detailed guidance fortheir own specialty. Practice can be audited againstthose standards both locally and by participating innational clinical audits, many <strong>of</strong> which are led by theRCP. The results <strong>of</strong> the national clinical audits arepublished so that individual units can learn about theirown performance and undertake programmes toimprove care. Specific details <strong>of</strong> the RCP programmesare outlined in Chapter 3 and on the RCP website.Health policyIn the 21st century, the context <strong>of</strong> clinical practice haschanged radically. While the four countries that make2 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


1 Physicians in the NHS todaycan be more cost-effective but this is a huge challenge –the alternative is indiscriminate cuts and a lowering inquality.Medical educationArrangements for medical education have recentlychanged. Regulation <strong>of</strong> postgraduate medical educationhas been moved to the General Medical Council (GMC)from the Postgraduate Medical Education and TrainingBoard (PMETB). The application system for medicaltrainees and the allocation <strong>of</strong> trainees to trainingprogrammes is now running more smoothly, after thedebacle <strong>of</strong> the original implementation <strong>of</strong> ModernisingMedical Careers. The recommendations <strong>of</strong> the Tookeenquiry 11 have been implemented and the RCP has ledthe way in making access to training in the medicalspecialties a smooth and fair process. In England, a newbody called Health Education England has beenestablished, <strong>with</strong> local education and training boards. Itis important that the medical workforce and educationis planned <strong>with</strong> an overall national strategy and the RCPwill be closely involved in trying to ensure that any newarrangements do not lower the quality and effectiveness<strong>of</strong> medical training.In the last decade, the number <strong>of</strong> graduates from UKmedical schools has increased. There have been changesto immigration rules which have cut the numbers <strong>of</strong>foreign non-EU graduates allowed to work and train inthe UK. This has led to some staffing difficulties as wellas denying training opportunities to overseas doctors,which the NHS has always <strong>of</strong>fered in the past. However,there is now the potential, for the first time, for the UKto have a self-sufficient medical workforce, which <strong>of</strong>fersthe opportunity <strong>of</strong> moving towards a fully consultantdeliveredspecialist service. However, to achieve this,numbers <strong>of</strong> medical staff and consultants must notbe cut.Continuing pr<strong>of</strong>essional developmentUntil now consultants who are fellows or members <strong>of</strong>the RCP have been required to demonstrate thatannually they have achieved 50 hours <strong>of</strong> CPD activity,half <strong>of</strong> which must be external to their employing trust,and in a 5-year cycle <strong>of</strong> 250 hours, 25 <strong>of</strong> those creditsmust be non-clinical activity. It is likely that thisrequirement will remain, for revalidation, but that thedemonstration <strong>of</strong> having taken part will be expandedupon, by requirements to demonstrate reflection andappropriate change <strong>of</strong> practice in response to thelearning event.As part <strong>of</strong> the terms and conditions <strong>of</strong> service forconsultants, there is a national agreement whichstipulates a minimum time allowed for study andpr<strong>of</strong>essional leave <strong>with</strong> funding, and it is expected thatall employers should honour this agreement. Detailsmay be negotiated locally as employers get moreautonomy, as in foundation trusts, but access toappropriate levels <strong>of</strong> CPD in order to keep up to dateand ensure ongoing quality <strong>of</strong> the medical workforce isessential for good patient care.RevalidationFollowing the Bristol and Shipman enquiries, 12 Sir LiamDonaldson, then chief medical <strong>of</strong>ficer in England,completed a review <strong>of</strong> medical regulation and publishedhisrecommendationsinthereport,Good doctors, safer<strong>patients</strong>. 13 This was followed by the white paper, Trust,assurance and safety, 14 and by the report <strong>of</strong> the chiefmedical <strong>of</strong>ficer for England’s Working Group, Medicalrevalidation: principles and next steps. 15 Thesedocuments provided an outline for the developmentand implementation <strong>of</strong> revalidation for doctors.This is a mechanism to show that all doctors are upto date and fit to continue practising. The RCP is<strong>working</strong> closely <strong>with</strong> the GMC, other colleges andpartners to develop the system <strong>of</strong> revalidation for<strong>physicians</strong>. Revalidation is the responsibility <strong>of</strong> theGMC but the RCP has made a major contribution topilots and the detailed work to make the systemtransparent and fair. From 2012 there has been anational requirement for all practising doctors torevalidate every 5 years.The medical royal colleges have responsibility for settingand maintaining specialist standards. Following wideconsultation by the GMC, 16 revalidation is now a singleprocess combining the original concepts <strong>of</strong> relicensureand specialist recertification. The proposed processhas also been streamlined, so that the minimumrequirements are to be five satisfactory annualappraisals, maintenance <strong>of</strong> CPD requirements,colleague and patient feedback, audit and qualityimprovement activity, and a review <strong>of</strong> critical incidents,complaints and compliments. The appraisal processitself has been strengthened and is being extensivelypiloted.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 5


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Changing environmentHealthcare is now delivered <strong>with</strong>in the context <strong>of</strong> arapidly changing society that is ageing andmulticultural, and has pockets <strong>of</strong> extreme affluence andpoverty. There are rising health inequalities, related tosocial inequalities. Society also needs to address diseasescaused as a result <strong>of</strong> excess and abuse in lifestyle: obesity,alcoholism and smoking. Tackling these diseases needschange from the government, society and the healthcaresector. The RCP is making major contributions to theseefforts, <strong>with</strong> our reports, education and attempts toinfluence the policy <strong>of</strong> the government.Our population is growing and getting older, <strong>with</strong> theaccumulation <strong>of</strong> chronic conditions and diseasesstrongly associated <strong>with</strong> older age – for example, risingincidences <strong>of</strong> cancer, dementia and frailty. Supportingcare for frail older people is a wider societal issue andprovision <strong>of</strong> services to support people as long aspossible in their own homes, living productiveindependent lives, requires close integration betweenhealth services, social care and the voluntary sector,recognising that most support to older people is givenby family and friends. The rising number <strong>of</strong> older<strong>patients</strong>, and <strong>of</strong> <strong>patients</strong> <strong>with</strong> chronic conditions,obesity and damage caused by excess alcohol ingestion,means that all <strong>physicians</strong> must have the skills to deal<strong>with</strong> these people, who may present <strong>with</strong> a wide variety<strong>of</strong> presentations and illnesses.There is also a need for consultant <strong>physicians</strong> to beinvolved <strong>with</strong> <strong>patients</strong> who are on the surgical wards,<strong>of</strong>fering expertise in the management <strong>of</strong> their medicalconditions which may deteriorate when they undergosurgery. 17 <strong>Consultant</strong> <strong>physicians</strong> and doctors in trainingare <strong>of</strong>ten called to deal <strong>with</strong> medical problems arising inpregnant women who are in the hospital. There is aneed for <strong>physicians</strong> who do not work directly <strong>with</strong>pregnant women to know more about the interactionbetween the conditions that they are treating andpregnancy. 18The RCP has published an analysis <strong>of</strong> the challengesfacing the acute medical services, Hospitals on the edge?(www.rcplondon.ac.uk/projects/hospitals-edge-timeaction),and has commissioned the Future HospitalCommission to come up <strong>with</strong> solutions to makecare more patient-focused, deploy the workforcein a different way and deal <strong>with</strong> the risingworkload in the acute sector. This will reportduring 2013.The training and development <strong>of</strong> theconsultant physicianThe reality for many healthcare pr<strong>of</strong>essionals hasinvolved coping <strong>with</strong> continuous change and risingworkload, <strong>with</strong> more complexity in the <strong>patients</strong> whomthey see. The ability to cope <strong>with</strong> repeatedreorganisations <strong>of</strong> healthcare, at a time <strong>of</strong> risingexpectations from <strong>patients</strong> and the public, needs to benurtured and supported, <strong>with</strong> flexibility <strong>of</strong> approachand a constant reference to the underlying values <strong>of</strong> thepr<strong>of</strong>ession and focus on the quality <strong>of</strong> care.Clinical practice is enabled and regulated <strong>with</strong>inframeworks that are common to all consultant<strong>physicians</strong> in the UK: The GMC is ultimately responsible for registrationand regulation. Most <strong>physicians</strong> in the UK work for the NHS, andwill be employed by an NHS organisation, usually ahospital or trust, which determines the environmentin which we practise. The departments <strong>of</strong> health set strategic objectivesresponding to the requirements <strong>of</strong> the governmentsin the devolved administrations. In addition, there are regulators and inspectors <strong>of</strong>practice, research and education, all <strong>of</strong> whichrequire attention and performance in their area <strong>of</strong>activity.Most medical consultants are employed by the NHS inhospital and community trusts, but the arrangementsdiffer in the four nations.They are all accredited specialists. <strong>Consultant</strong> <strong>physicians</strong>hold the Certificate <strong>of</strong> Completion <strong>of</strong> Training (CCT)previously awarded by the PMETB, now by the GMC.They are, <strong>with</strong> few exceptions, fellows or members <strong>of</strong>the <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians <strong>of</strong> London, Edinburghor Glasgow. Their training and development will havebeen supported in whole or part by one <strong>of</strong> these royalcolleges.At one time all consultant <strong>physicians</strong> were classed as‘general physician <strong>with</strong> a special interest’, for exampleconsultant physician <strong>with</strong> a special interest incardiology. However, as specialist subjects developedand expanded they reflected an increasingly complexbody <strong>of</strong> knowledge <strong>with</strong>in individual disciplines. Thereare now an increasing number <strong>of</strong> individual specialistsocieties associated <strong>with</strong> the RCP. Now, some6 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>have a daily visit from a consultant; in most hospitalsthis will involve more than one physician.Because many consultant <strong>physicians</strong> are already<strong>working</strong> longer hours than their contract stipulates, therecommendation means that, instead <strong>of</strong> increasing theamount <strong>of</strong> hours worked overall, job plans will need tochange to reflect the different <strong>working</strong> patterns andmust include arrangements to ensure adequate rest. Thestatement builds on previous RCP surveys, audits andreports on acute medicine, which have led toimprovements in the way acutely ill <strong>patients</strong> arecared for.Additional areas <strong>of</strong> work undertaken by <strong>physicians</strong> topromote personal and pr<strong>of</strong>essional excellence arecategorised as SPAs. Such activities include teaching,research, audit, self-development, management,quality improvement and wider contribution to theNHS. This work done in SPAs has expanded in natureand complexity. One example is the new arrangementfor the education and training <strong>of</strong> junior doctors,which requires that consultants who have juniorstaff should set aside about one hour each week tosupervise, educate and train each junior doctor.In a large team that is the equivalent <strong>of</strong> one halfday a week.In a standard <strong>working</strong> week <strong>of</strong> 10 sessions usually 7.5 <strong>of</strong>them will be devoted to clinical care and 2.5 to SPAs.Not all consultants will have 2.5 SPAs. Others <strong>with</strong>substantial educational, managerial qualityimprovement or research activities will have more.Many roles held at regional or national level shouldattract additional SPAs; this happens in some trusts, butnot others and is a contentious issue that is currentlyunder discussion nationally. <strong>Consultant</strong>s are stronglyencouraged to ensure that SPAs are recognised and paidforappropriately,butalsotorecognisethat2.5SPAsarenot a right and have to be justified.Excellence over and above just fulfilling contractualobligations to a satisfactory standard can be rewardedby the Clinical Excellence Awards scheme. 21Discretionary points can be allocated by local trustmanagement. Bronze, silver, gold and platinum awardscan be allocated by a national process, to rewardexcellence in service delivery, quality improvement,teaching, research or management. About 30% <strong>of</strong> allconsultants are in receipt <strong>of</strong> some sort <strong>of</strong> award, eitherlocal or national. The number <strong>of</strong> <strong>physicians</strong> who receivenational awards is proportionally higher than in othermedical disciplines. The scheme is under review andmay be changed after a period <strong>of</strong> consultation. The RCPhas submitted its view that the scheme does rewardexcellence and encourages the delivery <strong>of</strong> high-qualitycare and excellence in teaching, research, managementand clinical care.The changing role <strong>of</strong> the consultantover timeThe role <strong>of</strong> the modern consultant is expected todevelop and change during a pr<strong>of</strong>essional lifetime.<strong>Consultant</strong>s usually have three phases to theirpr<strong>of</strong>essional lives:1 establishment <strong>of</strong> clinical practice and vigorousinvolvement in it2 new responsibilities and roles <strong>with</strong>in their ownhospital3 leadership roles at local, regional and national level,for some.As part <strong>of</strong> this wider development some clinicians takemajor roles in clinical service development, qualityimprovement, management, research or education.These roles may be at local, regional or national level.Although not always <strong>of</strong> direct and immediate value tothe employing trust, they are important for the widerservice and add greatly to national strategic directionand support the drive for excellence.Additional duties that may be undertaken include: work on advisory panels for employment <strong>of</strong> otherconsultants lead for undergraduate education royal college tutor clinical tutor director <strong>of</strong> postgraduate medical education manager or director <strong>of</strong> service leadership <strong>of</strong> quality improvement processes clinical audit lead/governance lead.Within the health economy, activities can include: sessional commitments to primary careorganisations or regional bodies educational leads for undergraduate andpostgraduate education <strong>with</strong>in the deanery RCP regional advisers (RAs).8 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


1 Physicians in the NHS todayNationally they may include roles in the followingorganisations: medical royal colleges GMC Care Quality Commission Departments <strong>of</strong> Health National Institute for Health and Care Excellence(NICE) British Medical Association (BMA) National Clinical Assessment Service (NCAS).Supporting staff and facilitiesAll consultants require an <strong>of</strong>fice base <strong>with</strong> secretarialsupport and a pager or mobile phone. Some also needcomputer and internet access at home for results thatmay include radiology.The details will vary according to the specialty.‘Hot-desking’ and computer-sharing can function wellin some situations; the real question is whether thearrangements enable high-quality work.Some specialties work closely <strong>with</strong> scientists, specialistnurses and therapists, all <strong>of</strong> whom contribute to theextended clinical team and high-quality patient care.These staff <strong>of</strong>ten have additional skills contributing tomanagement, research teaching and audit.Doctors work very closely <strong>with</strong> nursing colleagues onthe hospital wards. It is essential that there is strongclinical leadership for the overall care <strong>of</strong> <strong>patients</strong>, andthat accountabilities are clear. A nurse should be presenton the ward rounds conducted by consultants, toensure that all issues are addressed. 22 Futuremanagement plans for <strong>patients</strong> need to be discussedbetween doctors and nurses, as well as other members<strong>of</strong> the healthcare team and the patient, <strong>with</strong> excellentcommunication, so that everyone is <strong>working</strong> towardsthe same goal.Physicians have a duty to keep good records and tocollect clinical information so that it can be used formonitoring their own performance and that <strong>of</strong> theteam, thus leading to improvements in care. Accurateinformation also enables better planning andmonitoring <strong>of</strong> services. This information must beaccurately coded and the aggregate results fed back toclinicians so that they can work to improve care to<strong>patients</strong>. The accurate collection and coding <strong>of</strong> clinicalinformation needs a partnership between <strong>physicians</strong>,coding and information staff, <strong>with</strong> adequateadministrative support.The changing medical workforceOver the past few years the medical specialty workforcehas undergone quite dramatic changes and the comingyears are likely to be as tumultuous, albeit in a differentway. The consultant body has continuously increasedand 11,810 doctors are employed as consultant<strong>physicians</strong> across the UK according to the RCP’s 2011census. 23 This expansion has been as a result <strong>of</strong> hugefinancial investment into the health structure <strong>of</strong> theUK which has given hospitals the freedom to developtheir services. Acute medicine has grown considerablyin this period <strong>of</strong> time (82.1%) <strong>with</strong> a total <strong>of</strong> 295consultants, which reflects the importance <strong>of</strong> thespecialty and the increased need for acute <strong>physicians</strong> bymost UK hospitals. Stroke medicine has grown the most(160 current consultants), although this was notdifficult as there were only seven self-declared strokespecialists in 2007.The consultant workforce remains predominantly malealthough this predominance is steadily changing <strong>with</strong>each year, as the large female trainee workforce attainsconsultant posts. There is a wide variation in theproportion <strong>of</strong> female consultants between specialties,from 9.6% in clinical pharmacology and therapeutics to71.3% in palliative medicine. The proportion <strong>of</strong>consultants <strong>working</strong> less than full time is 16.6%, anincrease from the previously recorded 13.2%, whichmay well reflect the increasing female consultant bodyand therefore may well continue to rise.There remains a considerable difference between largeand small medical specialties and between differentregions in England, and the different nations <strong>of</strong> the UKin terms <strong>of</strong> successful appointments <strong>of</strong> consultant posts.Most specialties have no problem appointingconsultants in the south-east <strong>of</strong> England but thisbecomes harder in other parts <strong>of</strong> England, Wales andNorthern Ireland. Many smaller specialties are currentlystruggling to fill both consultant posts and trainingposts and these specialties need to be carefullymonitored and planned nationally.The number <strong>of</strong> specialty registrars has remained steadyat 6,726 <strong>with</strong> 48.1% being female (<strong>with</strong> a wide variationbetween specialties).The large number <strong>of</strong> specialtyC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 9


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>registrars has significant implications for the future <strong>of</strong>these doctors. If all attain their CCT, taking on average 7years to do so, consultant expansion would have to be6–8% to accommodate them. However, it seems veryunlikely in the current financial climate that consultantexpansion will continue at the same pace as it has donefor the past few years and already there are considerableconcerns about the creation <strong>of</strong> a new grade <strong>of</strong> specialist,instead <strong>of</strong> traditional consultant posts. Diabetes andendocrinology have already seen a problem <strong>with</strong> theirtrainees getting posts and in some parts <strong>of</strong> the UK overa third <strong>of</strong> trainees have left the country once they haveobtained their CCT.The national framework for specialist workforceplanning has also changed considerably in England overthe past few years <strong>with</strong> the creation <strong>of</strong> the Centre forWorkforce Intelligence (CfWI) to replace the WorkforceReview Team. This organisation is an informationsource to allow workforce planning locally, but despitegood intention there remains considerable anxietyabout the quality <strong>of</strong> the data on the current workforce,let alone the models used to plan the future workforce(which do not take into account financial constraint).The medical specialties, the RCP and the CfWI need towork together over the next few years to ensure thatuniform data are used and that sensible predictions aremade to plan training numbers.Since the last edition <strong>of</strong> <strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong><strong>with</strong> <strong>patients</strong>, the European Working Time Directive(EWTD) has come into full force for junior doctors,reducing the number <strong>of</strong> hours that can be worked perweek to a maximum <strong>of</strong> 48. This has had a major impacton the provision <strong>of</strong> healthcare by doctors in hospitalsacross the UK and has cancelled out any benefit thatcould have been gained by the increased size <strong>of</strong> theworkforce. Furthermore, the restrictions that theEWTD has applied have resulted in the loss <strong>of</strong> on-call<strong>working</strong> for most junior doctors and the creation <strong>of</strong> fullshift rotas for nearly all bar consultants. It is interestingto note the impact this has had on consultants such that,in the 2011 census, 23 42.5% reported that they <strong>of</strong>ten hadto do jobs that would have previously been done byjunior doctors.New arrangements are coming into force in Englandfor specialist commissioning and for local educationand training boards. Together <strong>with</strong> the huge savingsthat are needed over the next few years, the medicalspecialty workforce will also face considerabledifficulties.Within the next few years the UK will, for the first time,become self-sufficient for medical graduates. With thiscomes the ability to fulfil the aspirations <strong>of</strong> achieving aworld-class NHS <strong>with</strong> a highly trained and motivatedmedical workforce.The future medical service will be consultant deliveredrather than consultant led. In some <strong>of</strong> the very acutespecialties this raises the possibility <strong>of</strong> full-shift <strong>working</strong>and round-the-clock presence <strong>of</strong> a consultant. This isbecause consultant-delivered care is better for <strong>patients</strong>and the hours worked by junior doctors are reducingsubstantially as a result <strong>of</strong> the EWTD and new trainingrequirements for doctors in training. The EWTDreduced the <strong>working</strong> week <strong>of</strong> the junior doctor from56 hours to 48 hours in 2009. There is a requirementnow for more structured teaching programmes fordoctors in training, <strong>with</strong> 4 hours <strong>of</strong> protected teachingtime each week and additional time for formalassessment and feedback, which takes a further hour <strong>of</strong>both the junior doctor and the consultant. The NewDealwasnegotiatedbytheBMAtogiveadequateresttime for junior doctors and to structure rotas aroundthe 56-hour <strong>working</strong> week. The rotas are now 48 hoursaweek.The consequence <strong>of</strong> these reductions <strong>of</strong> junior doctors’hours <strong>of</strong> work has been that they are less in evidenceduring the day and at night. The result <strong>of</strong> these changeshas been a gradual erosion <strong>of</strong> the consultant-led team <strong>of</strong>junior medical staff. This has had effects on access totraining and to continuity <strong>of</strong> care for <strong>patients</strong>. Oneparticular concern is that the wards during the day maynot have adequate junior doctor cover, if the juniormedical staff are on night rotas at that time. There aremoves to renegotiate the New Deal, to increaseflexibility. There are also discussions in Europe aboutchanging the application <strong>of</strong> the EWTD to juniordoctors. No one wants to see a return to fatigued juniordoctors <strong>working</strong> very long hours, but delivering trainingand good-quality patient care is proving to be verydifficult <strong>with</strong> the current inflexible arrangements abouthours <strong>of</strong> work.The workload <strong>of</strong> the medical registrar has become veryheavy and changes need to be made to have moredoctors on the wards and dealing <strong>with</strong> the emergencyintake (www.rcplondon.ac.uk/sites/default/files/future-medical-registrar 1.pdf).Moves to community care and the development <strong>of</strong>Teams <strong>with</strong>out walls, 24 which encompasses new10 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


1 Physicians in the NHS todayrelationships between specialists and GPs, will probablyrequire more and not fewer specialists coupled <strong>with</strong> newcontractual arrangements.There is also an increased need to be aware <strong>of</strong> the health<strong>of</strong> a local population and the incidence and prevalence<strong>of</strong> particular diseases to best plan patient pathwaysinvolving primary care and specialist care, as well aspublic health medicine.Changing delivery <strong>of</strong> medical careThe delivery <strong>of</strong> acute medical care has graduallychanged. The new specialty <strong>of</strong> acute medicine isproviding more <strong>of</strong> this service. The traditional role <strong>of</strong>the consultant general physician in acute medicine hasreduced in recent years. However, the rising number <strong>of</strong>medical admissions and the increasing number <strong>of</strong> frailolder people <strong>with</strong> a number <strong>of</strong> different conditionsmeans that we have to think seriously about the bestway to care for the acutely ill medical patient and thebest balance between specialists and general <strong>physicians</strong><strong>with</strong> an interest in a specialty.There is also a need for more specialist centres to givehighly specialised care to a population, eg thrombolysisin stroke, because every hospital dealing <strong>with</strong> acutemedical admissions may not give this treatment. Astechnology advances, there are merits in groupingexpertise together in specialised centres that cover abigger population than a local hospital. Thesedevelopments may drive the need for reconfiguration<strong>of</strong> hospitals.Working <strong>with</strong> <strong>patients</strong>Patients, relatives and carers are knowledgeable. Theyask questions, and expect and require answers. Theywant to be more involved in making decisions about thepattern <strong>of</strong> their care. Many now communicate <strong>with</strong>their doctors by text and email, asking questions derivedfrom internet searches. The doctor–patient relationshipis evolving towards a more open, honest and equalpartnership from which we all benefit. Physiciansincreasingly involve <strong>patients</strong> and their carers instrategic plans and developments as well as decisionsabout their individual treatment and care. There isincreased emphasis on shared decision-making between<strong>patients</strong> and their health pr<strong>of</strong>essional – the RCP istaking this work forward in partnership <strong>with</strong> others,including patient groups and the departments<strong>of</strong> health.The RCP has appointed a clinical fellow in SharedDecision Making and supportive self-management totake this agenda forward.Many <strong>physicians</strong> also work <strong>with</strong> patient groups toinform the development <strong>of</strong> services and there is muchevidence <strong>of</strong> that in the specialty sections <strong>of</strong> Chapter 2.As revalidation becomes a reality, individual patientfeedback to clinicians will become routine. The nextstep, where this does not already happen, will be to gainunderstanding and feedback from <strong>patients</strong> and carersabout the totality <strong>of</strong> the clinical service and to use thisinformation to guide further developments.There is a need for future work on how best to work<strong>with</strong> <strong>patients</strong> and the public, to involve them as truepartners in service development and to learn from theirperspectives to improve clinical care and services.The RCP has a well-established Patient InvolvementUnit. The role <strong>of</strong> this unit is to encourage and promotepatient, carer and public involvement in RCP activities,and to ensure that all plans and decisions made <strong>with</strong>inthe RCP have been considered in collaboration <strong>with</strong><strong>patients</strong>, carers and the public before implementation.In addition to employed staff the unit has a lay patientandcarerchairaswellasanRCP<strong>of</strong>ficer.Over60<strong>patients</strong> and carers are members <strong>of</strong> the Patient andCarer Network. Network members are recruitedthrough open advertisement in a variety <strong>of</strong> media,including the Big Issue. They complete an applicationand interview, and references are taken up beforeconfirmation <strong>of</strong> appointment for a 3-year tenure, <strong>with</strong>the option to extend by a further year.The lay chair is responsible for chairing the Patient andCarer Steering Group where the strategic aims <strong>of</strong> theunit are discussed and developed. The lay chair is also afull member <strong>of</strong> Council.The RCP has worked hard to ensure that patient andcarer involvement is integrated into all areas <strong>of</strong> itsbusiness. Every specialty medical committee/board hastwo patient/carer members. This involvement has beena key tool in ensuring that the RCP has considered andacted upon first-hand patient expertise and experience.All patient care pathways and chapters <strong>of</strong> this book havebeen considered and contributed to by the members <strong>of</strong>C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 11


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>the RCP Patient and Carer Network members via thesework streams.Patients and carers <strong>with</strong> long-term conditions havemany opportunities to observe what systems work andwhat systems could be improved <strong>with</strong>in healthcareservice delivery. The RCP document, Teams <strong>with</strong>outwalls, 24 highlighted the need to break down barriers(both physical and virtual) to improve healthcareservices resulting in improved care. Patients and carerssupported the production <strong>of</strong> this report, and are<strong>working</strong> hard to ensure that the content is embeddedinto <strong>working</strong> practice.Members <strong>of</strong> the Patient and Carer Network have beenable to inform the RCP on both where they feel areas <strong>of</strong>good practice exist and where there could beimprovement to patient care.The content <strong>of</strong> this book is a testament to theimprovements that have been made in approaches topatient and carer services and healthcare delivery. Thewidespread introduction <strong>of</strong> multidisciplinary teams,and work to remove barriers between different parts <strong>of</strong>the health service and different agencies have improvedpatient care. The future development <strong>of</strong> new approachesto education development and training, patient andcarer involvement, advanced patient care pathways, andpatient and carer feedback will continue to informfuture developments and improved patient care.It is essential that there is strong patient and carerinvolvement in future commissioning and servicedevelopment arrangements, if the needs <strong>of</strong> <strong>patients</strong> andcarersaretobemetappropriately.Themechanismforthis in England is unclear at present, <strong>with</strong> the changes <strong>of</strong>the new health Act, but it is essential that there is astrong patient and public voice in the development <strong>of</strong>future services.Academic medicineThe Cooksey report, published in 2006, introducedchanges to the way in which UK research was structuredand funded. 25,26 In the NHS the value <strong>of</strong> research isjudged increasingly on perceived health and societalneeds rather than scientific expertise alone. TheNational Institute for Health Research (NIHR) hasdeveloped an infrastructure through which theresearch-active physician should be able to contribute tothis vision. Despite this, challenges remain. Culturalchanges in the NHS place an increasing emphasis onclinical service over teaching and research.The potentially conflicting demands <strong>of</strong> employers (egNHS, universities, industry and grant-awarding bodies),those who fund research (eg national awarding bodiesand charities), and training and regulatory institutions(eg royal colleges and the GMC) need to be reconciled.The move towards a consultant-delivered clinicalservice and the workload relating to clinical governance,revalidation and CPD may mandate new ways <strong>of</strong><strong>working</strong>, and achieving a balance between clinical andacademic training, and geographical mobility will beneeded.Through a series <strong>of</strong> <strong>working</strong> parties and associatedpublications, the Academic Medicine Committee(AMC) <strong>of</strong> the RCP has attempted to address these issues.First, it has held workshops and published positionpapers concerning routes <strong>of</strong> entry and training systemsin academic medicine. 27 The need for a transparentcareer structure up to and including properly structuredand supported consultant posts has also been debated. 28Second, the AMC has been an integral part <strong>of</strong> the RCP’sMedicines Forum, leading the workstream relating totranslational research. Specifically it has identified waysin which the RCP can act as a link between nationalagencies and the research-active physician, therebyfacilitating the UK research agenda. Finally, the AMChas provided evidence to a number <strong>of</strong> investigations,consultations and reports, the most significant <strong>of</strong> whichhas been the 2011 report <strong>of</strong> the Academy <strong>of</strong> MedicalSciences into the burden <strong>of</strong> regulation impacting on UKresearch and clinical trials. 29SummaryThe context <strong>of</strong> clinical practice has changed rapidlysince the millennium and is set to change further.Revalidation, changes in medical education andresearch, and the expansion <strong>of</strong> the potential portfolio <strong>of</strong>the consultant coupled <strong>with</strong> a move towards aconsultant-delivered service and servicereconfiguration, pose challenges and unrivalledopportunities. There is a need for clinical leadership inmanagement, quality improvement, andcommissioning and planning <strong>of</strong> services.Better planning, support, education and training <strong>of</strong> theconsultant workforce are now needed to ensure that we12 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


1 Physicians in the NHS todaycan positively influence these changes and ensure thatpatient care not only remains at the centre <strong>of</strong> ourendeavours but continues to improve.References1 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Leading for quality: thefoundation for healthcare over the next decade. 2010.www.rcplondon.ac.uk/policy/responding-nhs-reform/leading-quality2 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Doctors in society: medicalpr<strong>of</strong>essionalism in a changing world.Report<strong>of</strong>a<strong>working</strong>party. London: RCP, 2005.3 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Future <strong>physicians</strong>: changingdoctors in changing times. London: RCP, 2010.4 WanlessD. Securing our future health: taking a long termview. London: HM Treasury, 2002.5 MarmotReviewTeam.Fair society: healthy lives. Themarmot review. London: Marmot Review, 2010. www.marmotreview.org.6 The House <strong>of</strong> Commons. Report <strong>of</strong> the Mid StaffordshireNHS Foundation Trust Public Inquiry. London: StationeryOffice, 2013. www.midstaffspublicinquiry.com/report7 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. A strategy for quality: 2011and beyond. www.rcplondon.ac.uk/policy/improvinghealthcare/rcp-strategy-for-quality.8 Department <strong>of</strong> Health. Equity and excellence: liberatingthe NHS. London: DH, 2010.9 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Care closer to home.www.rcplondon.ac.uk/resources/clinical-resources/carecloser-home.10 Department <strong>of</strong> Health. Ourhealth,ourcare,oursay:anew direction for community services. London:DH,2006.11 Tooke J. Aspiring to excellence: final report <strong>of</strong> theindependent inquiry into modernising medical careers.London: MMC Inquiry, 2008.12 Smith J. The Shipman Inquiry: fifth report. Safeguarding<strong>patients</strong>: lessons from the past – proposals for the future.London: Department <strong>of</strong> Health, 2004.13 Chief medical <strong>of</strong>ficer. Good doctors, safer <strong>patients</strong>.London: Department <strong>of</strong> Health, 2006.14 Department <strong>of</strong> Health. Trust, assurance and safety: theregulation <strong>of</strong> health pr<strong>of</strong>essionals. London:DH,2007.15 Medical revalidation – principles and next steps: the report<strong>of</strong> the Chief Medical Officer for England’s Working Group,July 2008. www.dh.gov.uk16 General Medical Council. Revalidation: a statement <strong>of</strong>intent. October 2010. www.gmc-uk.org17 National Confidential Enquiry into Patient Outcome andDeath. Elective and emergency surgery in the elderly: anage old problem. 2010. www.ncepod.org.uk18 Lewis G (ed). Centre for Maternal and Child Enquiries(CMACE). Saving mothers’ lives: reviewing maternaldeath to make motherhood safer. The Eighth Report <strong>of</strong> theConfidential Enquiries into Maternal Deaths in the UK.Br J Obstet Gynaecol 2011;118(suppl 1).19 Bell CM, Redelmeier DA. Mortality among <strong>patients</strong>admitted to hospital on weekends as compared <strong>with</strong>weekdays. N Engl J Med 2001;345:17:663–8.20 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Care <strong>of</strong> medical <strong>patients</strong> out<strong>of</strong> hours. Position statement. 2010.www.rcplondon.ac.uk/sites/default/files/RCP-positionstatement-care-<strong>of</strong>-medical-<strong>patients</strong>-out-<strong>of</strong>-hours.pdf21 Advisory Council on Clinical Excellence Awards.www.dh.gov.uk/ab/ACCEA22 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Nursing.Ward rounds in medicine – principles for best practice.London: RCP, 2012.23 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> theUnited Kingdom. Census <strong>of</strong> consultant <strong>physicians</strong> andmedical registrars in the UK, 2011: data and commentary.London: RCP, 2013.24 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> GeneralPractitioners, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Paediatrics and ChildHealth. Teams <strong>with</strong>out walls: the value <strong>of</strong> medicalinnovation and leadership.Report<strong>of</strong>a<strong>working</strong>party.London: RCP, 2008.25 Cooksey D. A review <strong>of</strong> UK health research funding.London: DH, 2006.26 Department <strong>of</strong> Health. Best research for best health: a newresearch strategy. London: DH, 2006.27 Thompson DG, Evans TW. Coordinating academictraining for <strong>physicians</strong>. Clin Med 2009;7:542–3.28 Thompson DG, Mathieson P, Wynick D, et al.TheNHSacademic vision: training the <strong>physicians</strong> to deliver it. ClinMed 2011;11:109–10.29 Academy <strong>of</strong> Medical Sciences. A new pathway for theregulation and governance <strong>of</strong> health research. London:AMS, 2011.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 13


2 The work <strong>of</strong> the specialties2 The work <strong>of</strong> the specialtiesThis chapter describes the work <strong>of</strong> the specialties,written to a structured format. Each submission hasseven main sections followed by specimen workprogrammes, consultant job plans and key points forcommissioners:1 Description <strong>of</strong> the specialty2 Organisation <strong>of</strong> the service and patterns <strong>of</strong> referral3 Working <strong>with</strong> <strong>patients</strong>: patient-centred care4 Interspecialty and interdisciplinary liaison5 Delivering a high-quality service6 Clinical work <strong>of</strong> consultants7 Opportunities for integrated care8 Workforce requirements for the specialty9 <strong>Consultant</strong> work programmes/specimen job plans10 Key points for commissionersThe editor would like to especially thank all <strong>of</strong> thecontributors who freely gave their time and energy, andwho are listed below.List <strong>of</strong> contributors for the specialtiesJeffrey Aronson Honorary consultant physician,University <strong>of</strong> Oxford and Oxford University HospitalsNHS TrustRuth M Ayling <strong>Consultant</strong> chemical pathologist,Derriford Hopsital, PlymouthDr Marwan Bukhari <strong>Consultant</strong> rheumatologist,University Hospitals <strong>of</strong> Morecombe Bay NHSFoundation TrustChristopher B Bunker <strong>Consultant</strong> dermatologist,University <strong>College</strong> London Hospital; honorarypr<strong>of</strong>essor, University <strong>College</strong> London; president,British Association <strong>of</strong> DermatologistsJohn Buscombe <strong>Consultant</strong> physician in nuclearmedicine, Cambridge University HospitalsChristopher P Conlon Reader in infectious diseasesand tropical medicine, University <strong>of</strong> Oxford;consultant in infectious diseases, NuffieldDepartment <strong>of</strong> Medicine, John Radcliffe Hospital,OxfordBen Cottam Policy and communications coordinator,Faculty <strong>of</strong> Pharmaceutical Medicine, LondonLisa Davies <strong>Consultant</strong> respiratory physician, AintreeUniversity Hospital NHS Foundation TrustSabina Dizdarevic <strong>Consultant</strong> in nuclear medicine,Brighton and Sussex University Hospitals NHSTrustRhid Dowdle <strong>Consultant</strong> physician and cardiologist,<strong>Royal</strong> Glamorgan Hospital, Cwm Taf Local HealthBoardPamela Ewan <strong>Consultant</strong> allergist, CambridgeUniversity Hospitals NHS Foundation TrustEJaneFlint<strong>Consultant</strong> cardiologist, on behalf <strong>of</strong><strong>of</strong>ficers and Affiliated Groups <strong>of</strong> the BritishCardiovascular SocietyFrances A Flinter <strong>Consultant</strong> in clinical genetics,Guy’s & St Thomas’ NHS Foundation TrustRichard P Gale <strong>Consultant</strong> medical ophthalmologist,York Teaching Hospital; chair, MedicalOphthalmology SACMike Galloway <strong>Consultant</strong> haematologist; formerchair, Intercollegiate Committee on HaematologyGe<strong>of</strong>f Gill <strong>Consultant</strong> physician (diabetes andendocrinology), Aintree University Hospital,LiverpoolStephanie Gomm <strong>Consultant</strong> palliative medicine,Salford <strong>Royal</strong> NHS Foundation Trust; chair, JointSpecialty Committee Palliative MedicineCatherine Guly <strong>Consultant</strong> medical ophthalmologist,University Hospitals Bristol NHS Foundation TrustAdam Harris <strong>Consultant</strong> physician andgastroenterologist, The Tunbridge Wells Hospital;chair, British Society <strong>of</strong> Gastroenterology, ClinicalServices & Standards CommitteeSebastian Hendricks <strong>Consultant</strong> audiovestibularphysician and paediatrician, Barnet and Chase FarmHospital NHS TrustStephen Jackson Pr<strong>of</strong>essor <strong>of</strong> clinical gerontology,King’s <strong>College</strong> Hospital Foundation Trust and King’s<strong>College</strong> LondonJohnathan J<strong>of</strong>fe Chair, Association <strong>of</strong> CancerPhysicians; consultant medical oncologist,Huddersfield <strong>Royal</strong> InfirmaryC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 15


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Stephen K Jones <strong>Consultant</strong> dermatologist, WirralUniversity Teaching Hospital; chair, Joint SpecialtyCommittee Dermatology, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians,LondonRosalind Kandler <strong>Consultant</strong> clinicalneurophysiologist, <strong>Royal</strong> Hallamshire Hospital,SheffieldRobin Kennett <strong>Consultant</strong> clinical neurophysiologist,John Radcliffe Hospital, Oxford; BSCN presidentNick J Levell Clinical director dermatology, Norfolkand Norwich University Hospital; president, BritishSociety for Medical DermatologyVal Lewington Pr<strong>of</strong>essor <strong>of</strong> nuclear medicine, King’s<strong>College</strong> LondonJ Gareth Llewelyn <strong>Consultant</strong> neurologist andhonorary senior lecturer, Aneurin Bevan Health Boardand Cardiff and Vale University Health Board, Wales;chair, Services and Standards Committee, Association<strong>of</strong> British NeurologistsBreege Mac Ardle <strong>Consultant</strong> in audiovestibularmedicine, <strong>Royal</strong> National Throat Nose and EarHospital; UCLH NHS Foundation TrustJanine Mansi Honorary secretary, Association <strong>of</strong>Cancer Physicians; consultant medical oncologist,Guy’s & St Thomas’ NHS Foundation TrustPhilip D Mason <strong>Consultant</strong> nephrologist, OxfordKidney Unit, The Churchill Hospital, OxfordJohn P McCann <strong>Consultant</strong> in rehabilitationmedicine, Belfast Health and Social Care Trust,BelfastSiraj A Misbah <strong>Consultant</strong> clinical immunologist, leadfor clinical immunology, Oxford University HospitalsShuaib Nasser <strong>Consultant</strong> allergist, CambridgeUniversity Hospitals NHS Foundation TrustJ Brian Neilly <strong>Consultant</strong> physician, Glasgow <strong>Royal</strong>InfirmaryJohn Newell-Price Reader in endocrinology,consultant endocrinologist human metabolism,School <strong>of</strong> Medicine and Biomedical ScienceHelen Newton Locum consultant physician, TheHorton General Hospital, Oxford University HospitalsNHS TrustAlison Norton Administrator, Association <strong>of</strong> CancerPhysiciansMunir Pirmohamed <strong>Consultant</strong> physicianpharmacology, <strong>Royal</strong> Liverpool and BroadgreenUniversity Hospital NHS Trust and University <strong>of</strong>LiverpoolLiz Prvulovich <strong>Consultant</strong> physician nuclearmedicine, University <strong>College</strong> London Hospitals NHSFoundation TrustRuth Richmond <strong>Consultant</strong> rheumatologist, BordersGeneral Hospital NHS TrustJames Ritter Honorary consultant physician, Guy’sand St Thomas’ Foundation Trust and King’s <strong>College</strong>LondonIan Rowe <strong>Consultant</strong> rheumatologist, WorcestershireAcute Hospitals NHS TrustChristopher W Roy Retired consultant inrehabilitation medicine (formerly Southern GeneralHospital), GlasgowAndrew Scarsbrook Nuclear medicine physician,Leeds Teaching Hospitals NHS TrustJackie Sherrard <strong>Consultant</strong> genitourinary physician,Churchill Hospital, OxfordNeil Snowden <strong>Consultant</strong> rheumatologist, PennineMusculoskeletal Partnership and Pennine AcuteHospitals TrustDan Stark Workforce lead for SAC in MedicalOncology, St James’s Institute <strong>of</strong> Oncology, LeedsCharles R V Tomson <strong>Consultant</strong> nephrologist,Southmead Hospital, North Bristol NHS TrustPeter D Turnpenny consultant clinical geneticist,<strong>Royal</strong> Devon & Exeter HospitalDolores Umapathy <strong>Consultant</strong> in audiovestibularmedicine, Bolton NHS Foundation TrustChristopher D Ward Retired pr<strong>of</strong>essor <strong>of</strong>rehabilitation medicine, University <strong>of</strong> Nottingham,School <strong>of</strong> Graduate Entry Medicine and HealthBee Wee <strong>Consultant</strong> and senior clinical lecturer inpalliative medicine, Sir Michael Sobell House, OxfordUniversity Hospitals NHS Trust; fellow <strong>of</strong> HarrisManchester <strong>College</strong>, University <strong>of</strong> OxfordGraeme Wilkes <strong>Consultant</strong> in sport and exercisemedicine, Connect Physical Health, Newcastle uponTyneWilby Williamson Academic clinical fellow in sportand exercise medicine, Oxford University Hospitals,OxfordZoe Wyrko <strong>Consultant</strong> geriatrician, Queen ElizabethHospital Birmingham16 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Acute internal medicine and general internal medicineAcute internal medicine and general internal medicineDr Rhid Dowdle OBE MB BChir FRCP FEFIM FSAM <strong>Consultant</strong> physicianand cardiologist1 Description <strong>of</strong> the specialtyI have heard the fear expressed that in this countrythe sphere <strong>of</strong> the physician proper is becoming moreand more restricted, and perhaps this is true; but Imaintain . . . that the opportunities are still great, thatthe harvest truly is plenteous, and the labourers scarcelysufficient to meet this demand.Sir William Osler, 1897Acute internal medicineAcute internal medicine (AIM) is defined as ‘that part <strong>of</strong>general internal medicine (GIM) concerned <strong>with</strong> theimmediate and early specialist management <strong>of</strong> adult<strong>patients</strong> suffering from a wide range <strong>of</strong> medicalconditions who present to, or from <strong>with</strong>in, hospitals,requiring urgent or emergency care’. 1,2 All <strong>physicians</strong>participating in the acute medical intake should havethe skills to manage any patient presenting <strong>with</strong> anacute medical problem for up to 72 hours, whether theypractise AIM as a sole specialty or GIM <strong>with</strong> anotherspecialty. However, consultant <strong>physicians</strong> specialising inAIM – acute <strong>physicians</strong> – are expected not only toparticipate in the delivery <strong>of</strong> acute care but also to leadin the organisation <strong>of</strong> care for acutely ill <strong>patients</strong>. Acute<strong>physicians</strong> should provide the clinical andorganisational lead for the assessment wards and theacute medical unit (AMU) and <strong>of</strong>ten now act as thelead clinicians for the organisation <strong>of</strong> acute carethroughout the hospital, particularly in the context <strong>of</strong>hospital at night and the out-<strong>of</strong>-hours medical team(OoHMT). 2General internal medicineThere remains a need for most <strong>physicians</strong> who havecontinuing responsibility for in<strong>patients</strong>, other thanthose on the AMU, to have the skills to manage <strong>patients</strong>suffering a variety <strong>of</strong> common disorders or havingcomplex needs. Although many hospitals admit <strong>patients</strong><strong>with</strong> acute illnesses to the most appropriate specialtiessoon after their admission, there are still circumstanceswhere this cannot or does not take place. This mayoccur where the patient’s illness does not fit the criteriaused to define the appropriateness <strong>of</strong> specialtycare or in smaller hospitals where specialty care isnot always practicable and <strong>patients</strong> remain under thecare <strong>of</strong> the admitting team. This inpatient work,together <strong>with</strong> the management <strong>of</strong> the acute take,defines GIM.All the curricula, both in AIM and in GIM, are based onthe symptoms <strong>with</strong> which <strong>patients</strong> present, emphasisingthe critical part that diagnosis plays in delivering goodpatient care. 3 The majority <strong>of</strong> current trainees in AIMare dually training <strong>with</strong> GIM, which <strong>of</strong>fers flexibility incareer progression, and many aspire to accreditation inintensive care medicine as well.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralTraditionally, the acute medical intake has beenmanaged by general <strong>physicians</strong> <strong>with</strong> an additionalinterest in a particular specialty, and such <strong>physicians</strong> arelikely to continue to provide the majority <strong>of</strong> theconsultant workforce in this situation for the immediatefuture. However, increasing numbers <strong>of</strong> acute<strong>physicians</strong> are being trained and appointed to leadthe service and to develop alternatives to orthodoxcare.Most hospitals have now created specific units for theassessment and treatment <strong>of</strong> acute medical emergencies– a strategy supported by the National ConfidentialEnquiry into Patient Outcome and Death (NCEPOD). 4The <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP) recommendsthat the term AMU now be adopted for these facilities 2and the report <strong>of</strong> the RCP’s Acute Medicine Task Forceprovides a detailed description <strong>of</strong> the rationale andrequirements for AMUs. 2 Although small hospitals mayfunction successfully <strong>with</strong>out such units, it has beenshown that, in larger hospitals, AMUs can enhance thequality <strong>of</strong> care for the acutely ill medical patient andfocus attention on the admission process itself. 5 AllC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 17


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>AMUs should have a designated clinical lead 4,6 andwhereanacutephysicianisinpostthisshouldbepart<strong>of</strong>his or her duties. Some hospitals have developedfacilities combining the assessment <strong>of</strong> both medical andsurgical <strong>patients</strong> in a single multispecialty assessmentunit. Where this occurs, the functions <strong>of</strong> the AMUshould be subsumed into such units.Patients may present as referrals from primary care,from emergency medicine (the accident and emergencydepartment) or from <strong>with</strong>in the hospital inpatientpopulation. The majority <strong>of</strong> <strong>patients</strong> will be elderly,many <strong>with</strong> a number <strong>of</strong> comorbidities, frailties anddementia. Direct admissions to AMUs are encouragedto facilitate prompt care. 23 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareIn the past, the service was based upon the care <strong>of</strong><strong>patients</strong> whose need for admission had been previouslydetermined. Nowadays there is an increasing emphasison assessment and treatment rather than admission,including the provision <strong>of</strong> alternatives to admission.These alternatives include immediate out<strong>patients</strong>ervices – rapid access clinics – <strong>with</strong> specialist clinics forconditions such as cerebral transient ischaemic attacks(TIAs), chest pain and ambulatory emergency care(AEC). Ambulatory care in particular is a directdevelopment <strong>of</strong> the acute medicine movement and isdefined as ‘clinical care which may include diagnosis,observation, treatment and rehabilitation, not provided<strong>with</strong>in the traditional hospital bed base or <strong>with</strong>in thetraditional outpatient services, and that can be providedacross the primary/secondary care interface’. 2,7,8 Suchdevelopments have provided practitioners and <strong>patients</strong><strong>with</strong> choices for their care that were not previouslyavailable. The development <strong>of</strong> AMUs has meant thatmany <strong>patients</strong> can be admitted for short periods<strong>with</strong>out transfer to a traditional inpatient ward. Inlarger hospitals, issues <strong>of</strong> scale have also allowed thedevelopment <strong>of</strong> specialist short-stay units andambulatory care units. 24 Interspecialty and interdisciplinaryliaisonMultidisciplinary team <strong>working</strong>Acute medicine demands good multidisciplinary team(MDT) <strong>working</strong>, <strong>with</strong> input from bed managers and thedischarge liaison team, physiotherapists, 9 occupationaltherapists and pharmacists as well as specialist nurses.Working <strong>with</strong> other specialtiesAcute medicine relates to the other medical specialtiesin a variety <strong>of</strong> ways. In many hospitals, <strong>patients</strong> areassessed, given initial treatment and then referred to thespecialty most appropriate for their continuing careshortly after admission. 5 Alternatively, particularly inlarger hospitals, there may be regular AMU wardrounds by clinicians from the major specialties toidentify <strong>patients</strong> best suited for specialist care and toadvise on the care <strong>of</strong> others. Prompt access to specialistopinions and care is essential for optimal patient care.Acute medicine has particularly important relationships<strong>with</strong> emergency medicine and critical care. Theserelationships are described in the RCP documentsInterface <strong>of</strong> accident and emergency and acute medicine 10and Interface between acute general medicine and criticalcare, 11 and are discussed in detail in Acute medical care. 2Working <strong>with</strong> general practitioners (GPs)The AMU also provides an opportunity for GPs to workin acute care <strong>with</strong>in hospitals and such <strong>working</strong> canprovide a valuable channel <strong>of</strong> communication betweenprimary and secondary care. 12 Conversely, theadmitting physician <strong>working</strong> <strong>with</strong> an effective bedbureau or bed management team can be a point <strong>of</strong>contact for GPs to obtain clinical advice on patient careand to discuss alternatives to direct admission.5 Delivering a high-quality serviceRCP recommendations for the assessment processAny hospital admitting acutely ill medical <strong>patients</strong>should have a consultant physician on site for at least 12hours per day, 7 days a week, and that physician shouldhave no other duties scheduled during this time. Atnight, <strong>physicians</strong> should cover on-call duty from homebut must be prepared to return to the hospital torespond to the needs <strong>of</strong> acutely ill <strong>patients</strong> who mayhave presented during the out-<strong>of</strong>-hours period. 13An assessment <strong>of</strong> the severity <strong>of</strong> a patient’s illnessshould be made immediately upon arrival on the AMU.This assessment should use a validated assessment or‘track-and-trigger’ tool. The Acute Medical Task Forcerecommended that there should be a single such systemacross the NHS and the RCP recommends the NHSEarly Warning Score (NEWS). 1418 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Acute internal medicine and general internal medicineThe initial care <strong>of</strong> all <strong>patients</strong> should be dictated by theirclinical need and the severity <strong>of</strong> the illness atpresentation.When a patient is found to be seriously ill, his or hercare should be directly provided by the most seniordoctor readily available. This should be a consultant orspecialty registrar (StR) and possession <strong>of</strong> themembership <strong>of</strong> the RCP, MRCP(UK), should be theminimum qualification for this task.A severely ill patient may require resuscitation andimmediate care before a formal clerking can be carriedout.The RCP recommends that a foundation or coremedical training (CMT) doctor should be allowed oneand a half hours to complete the formal assessment <strong>of</strong> apatient presenting to hospital <strong>with</strong> an acute medicalproblem. This would include: carrying out a clinical assessment documenting that assessment arranging appropriate investigations gathering the results <strong>of</strong> those investigations assessing the patient’s risk <strong>of</strong> venousthromboembolism assessing the patient’s risk <strong>of</strong> acute kidney injury carrying out a diagnostic synthesis and derivingdifferential diagnoses drawing up an appropriate care plan including aclear monitoring plan specifying the physiologicalobservations to be recorded and their frequency initiating treatment where appropriate reporting the case to an appropriate senior doctor.All <strong>patients</strong> should have their formal assessmentcompleted <strong>with</strong>in 4 hours <strong>of</strong> their admission. 2Amoreseniordoctor<strong>with</strong>appropriateskillsinacutemedicine should be based in the AMU at all times. Thisshould be an StR 3+, or equivalent middle-gradedoctor, who should have the MRCP(UK) qualificationand at least 2 years’ recent experience <strong>of</strong> managingacutely ill <strong>patients</strong>. When <strong>working</strong> on the AMU, theyshould have no other scheduled commitments. 1,2There must always be consultant supervision <strong>of</strong> themedical team on call and the identity <strong>of</strong> the supervisingconsultant should always be known to the medical staffon call and to other relevant staff. There should be clearmechanisms in place to involve the consultant at anearly stage in the care <strong>of</strong> <strong>patients</strong> who are particularlyunwell.During the extended <strong>working</strong> day, the consultant on callshould review <strong>patients</strong> as soon as possible after theirformal assessment has been completed – ‘rolling review’.As a minimum standard, during the <strong>working</strong> day thisreview should take place <strong>with</strong>in 6–8 hours <strong>of</strong> thepatient’s admission to the AMU. Patients admittedovernight should receive a consultant review <strong>with</strong>in 14hours. 15In addition to the review <strong>of</strong> newly assessed <strong>patients</strong>, theconsultant on call should also review all <strong>patients</strong> whoremain on the AMU. These tasks will require aconsultant-led post-take ward round at least twice a day,7daysaweek.All <strong>patients</strong> admitted into the hospital from the AMUshould have been reviewed by the consultant on call,who should agree or modify the care plan proposed atthe patient’s formal assessment. Exceptionally, a seniorStR could deputise for the consultant on call in this role.Planning for the patient’s discharge should start as soonas possible after admission.Any patient leaving the AMU, or remainingthere over a change <strong>of</strong> shift, should have details <strong>of</strong>his or her situation passed on to the clinicians assumingresponsibility for their continuing care. This handover<strong>of</strong> information and responsibility is vital for goodpatient care. The handover process should thereforebe robust, clearly understood and regularly audited asdescribed in the RCP Acute care toolkit 1: Handover. 16–18Patients transferred out <strong>of</strong> AMU should receive promptreview on their new ward, <strong>with</strong> a consultant review<strong>with</strong>in 24 hours <strong>of</strong> the transfer, 7 days a week. Thisshould be a priority duty in the first hour <strong>of</strong> the<strong>working</strong> day – ‘golden hour’ review. 19Maintaining and improving the quality <strong>of</strong> careEducation and trainingThe acute medical intake provides a unique forum fortraining medical and other staff and students involved inthe care <strong>of</strong> the acutely ill patient. <strong>Consultant</strong>s are expectedto ensure that learning opportunities are taken upwhenever possible. The General Medical Council (GMC)has approved a variety <strong>of</strong> assessment tools for juniormedical staff, particularly the Acute Care AssessmentTool (ACAT), which can be carried out in the context<strong>of</strong> the acute medical intake. Senior StRs approachingC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 19


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>the end <strong>of</strong> their training should have the experience<strong>of</strong> leading the post-take round under the supervision<strong>of</strong> the consultant on call. Detailed recommendationsfor education and training are includedin the RCP report Acute medical care 2 and the RCPAcute care toolkit 5: Teaching on the acute medical unit. 20Continuing pr<strong>of</strong>essional developmentIt is clearly important that all consultants involved inthe supervision <strong>of</strong> the acute medical intake are familiar<strong>with</strong> current recommended practices in themanagement <strong>of</strong> common emergency presentations. Tothis end, part <strong>of</strong> their study leave and continuingpr<strong>of</strong>essional development (CPD) should be committedto acute medicine. 2 All aspects <strong>of</strong> a consultant’s CPDshould be discussed and planned as part <strong>of</strong> his or herannual appraisal.Acute <strong>physicians</strong> will have similar needs for CPD. Inaddition to maintaining a good knowledge <strong>of</strong> currentbestpractice,itislikelythatnewroleswillfalltoacute<strong>physicians</strong> who will need to develop new skills andcompetences; the thrombolysis <strong>of</strong> acute ischaemicstroke is an example.General <strong>physicians</strong> are responsible for the continuingcare <strong>of</strong> <strong>patients</strong> whose disorders are not appropriate forspecialist care <strong>with</strong>in their hospitals. Their CPD willneed to include the acquisition and maintenance <strong>of</strong>expertise in the management <strong>of</strong> these <strong>patients</strong>. Thiscould include, for instance, <strong>patients</strong> <strong>with</strong> neurologicalor renal disorders or infectious diseases.Clinical governanceAll AMUs should have a clinical governance strategythat includes monitoring <strong>of</strong> 24-hour mortality, 7-dayreadmission and direct discharge rates. 6,21 All AMUsshould also have a written and dated operational policythat is reviewed regularly. Quality standards for AMUshave been published jointly by the West MidlandsQuality Review Service and the Society for AcuteMedicine 22 and clinical quality indicators for AMUshave also been published by the Society for AcuteMedicine (SAM). 23ResearchAcute medicine needs to develop a strong research baseand all <strong>physicians</strong> involved in the acute medical intakeare encouraged to seek opportunities for research thatwill build an evidence base for best acute practice. Acutemedical units provide the potential to undertake clinicalresearch on a variety <strong>of</strong> acute clinical problems, as wellas opportunities to review the role <strong>of</strong> technology inimproving healthcare. This is particularly the case foracute <strong>physicians</strong>.Regional and national workAcute <strong>physicians</strong> are expected to be as equally involvedas their peers in regional and national work <strong>with</strong> themedical royal colleges, Department <strong>of</strong> Health (DH),deaneries and specialist societies such as the SAM.National guidelines and auditThe RCP publication Acute medical care 2 providesdetailed recommendations for the organisation <strong>of</strong> care<strong>of</strong> the acutely ill medical patient. This has beenendorsed by the SAM, which has published similarrecommendations, as have the National Institute forHealth and Care Excellence (NICE) and the ScottishIntercollegiate Guideline Network (SIGN). Guidelinesfor the medical management <strong>of</strong> many acutepresentations have been formulated by a number <strong>of</strong>agencies, including specialist societies such as theBritish Thoracic Society (BTS).NICE clinical guideline 50 Acutely ill <strong>patients</strong> inhospital 24 includes a general audit <strong>of</strong> the care <strong>of</strong> theacutely ill medical patient and the NCEPOD reportEmergency admissions: a journey in the right direction?has a self-assessment checklist. 46 Clinical work <strong>of</strong> consultantsThe RCP has recommended movement towards a moreconsultant-delivered service, available 7 days a week.Hospitals undertaking the admission <strong>of</strong> acutely illmedical <strong>patients</strong> should have a consultant physician onsite for at least 12 hours per day, 7 days a week, whoseprimary role is to manage the acute medical intake. 13Provision should also be made for a daily consultantvisit to all medical wards on weekends and holidays. Thepurpose <strong>of</strong> this visit is not only to address new problemsthat have arisen overnight but also to progress patientcare where possible. In many hospitals, this will requireinput from more than one physician 13 andshouldbesupported by junior medical staff. It is also recognisedthat consultant job plans will need to correctly reflectthis extra work, which is programmed activities (PAs)undertaken in premium time. Arrangements will beneeded to ensure adequate rest for the consultantsinvolved. Other specialties and support services will alsoneed to adopt 7-day <strong>working</strong> practices if the full benefit<strong>of</strong> this additional input by <strong>physicians</strong> is to be realised. 820 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Acute internal medicine and general internal medicineDetailed recommendations for the implementation <strong>of</strong>7-day consultant <strong>working</strong> in the AMU are made in theRCP Acute care toolkit 4: 12-hour, 7-day consultantpresence on the acute medical unit. 15With the on-call consultant present in the hospital for12 hours daily, typical hours <strong>of</strong> work would be from8am to 8pm. During the <strong>working</strong> week, this predictableemergency work would represent three sessions <strong>of</strong> PAsin direct clinical care, mainly in non-premium time.Similar <strong>working</strong> on weekends and during holidays, inpremium time, would represent four sessions <strong>of</strong> PAs indirect clinical care.<strong>Consultant</strong> work patterns should include protectedsessional time for AMU work, ideally in blocks <strong>of</strong> days.Single-day rotas contribute to poor continuity <strong>of</strong> carebut 7-day blocks are considered too onerous. Precisework patterns should be developed to reflect local needs.All other clinical duties and responsibilities should becancelled for all clinical staff <strong>working</strong> on AMU orparticipating in the direct supervision <strong>of</strong> the acutemedical intake. 2,13 A consultant’s eligibility to continueparticipating in the acute take should be assessedannually during his or her appraisal. Theserecommendations are equally applicable where theintake is managed by an acute physician or by aphysician <strong>with</strong> another specialty interest who isqualified to lead the acute medical intake.The work <strong>of</strong> an acute physicianAcute medicine is a young discipline, and as such itsstyle <strong>of</strong> <strong>working</strong> is still in evolution. However, it isapparent that there is more opportunity for variety <strong>of</strong>practice in acute medicine than in many otherspecialties. Classic acute <strong>physicians</strong> will normally haveaccess only to beds on the AMU, where their <strong>patients</strong>’length <strong>of</strong> stay is usually limited to between 24 and 72hours. Acute <strong>physicians</strong> are therefore able to manage thetotal episode <strong>of</strong> care <strong>of</strong> <strong>patients</strong> who do not require alonger admission. Managing <strong>patients</strong> in the AMU, or itsrelated short-stay unit, is beneficial in minimising thenumber <strong>of</strong> ward-to-ward transfers which are disruptiveto care. The acute physician should also have time tomanage alternative strategies to admission, such asambulatory emergency care and rapid access clinics.In addition to work on the AMU, the RCP recognisesthe value <strong>of</strong> the acute physician in ensuring closerelationships <strong>with</strong> all medical specialties and <strong>with</strong>emergency medicine and critical care. 10,11 Sessionalwork in either <strong>of</strong> these fields would be appropriate foracute <strong>physicians</strong> who have the required competencies.Similarly, it may be appropriate for an acute physicianto retain an interest in another discipline in which he orshe has demonstrated the relevant competencies, such asthoracic medicine or gastroenterology, or in proceduressuch as echocardiography. This can be maintained bycontinuing sessional work in that field. Other modelsexist where a significantly greater proportion <strong>of</strong> <strong>working</strong>time is spent in another discipline or where there is acycle <strong>of</strong> differing activities, such as <strong>working</strong> for periods<strong>of</strong> one or more weeks in acute medicine andsubsequently similar periods in another discipline.All acute <strong>physicians</strong> should have the competencies todeliver high dependency care to most <strong>patients</strong> <strong>with</strong>medical needs defined as level 2 by the Intensive CareSociety. 8,25 In some hospitals, a medical highdependency unit could be embedded <strong>with</strong>in the AMU. 2Inpatient workThe usual day-to-day work <strong>of</strong> an acute physician caninclude a formal contribution to the supervision <strong>of</strong> theacute medical intake as the sole responsible consultantfor a period <strong>of</strong> time. Alternatively, an acute physicianmight work together <strong>with</strong> another consultant, seekingthe more severely ill <strong>patients</strong> for early assessment or<strong>patients</strong> suitable for management as short-stay orambulatory emergency care <strong>patients</strong>. Where a number<strong>of</strong> acute <strong>physicians</strong> are in post, their contribution to thesupervision <strong>of</strong> the acute medical intake will obviouslybe greater.Outpatient workOutpatient work in acute medicine is divided betweenrapid access clinics, which usually <strong>of</strong>fer same-day ornext-day appointments for selected <strong>patients</strong>, andambulatory emergency care. In the outpatient service,the numbers <strong>of</strong> <strong>patients</strong> seen should follow therecommendations for a number <strong>of</strong> specialties –approximately 30 minutes should be allocated for a newpatient and 15 minutes for a follow-up appointment. Inambulatory care, it is more difficult to define setnumbers because the <strong>patients</strong> managed in this way aremore varied.The work <strong>of</strong> a general physicianGeneral internal medicine is the origin <strong>of</strong> many medicalspecialties and is at the heart <strong>of</strong> <strong>physicians</strong>’ work. Thereare two components to the work <strong>of</strong> a general physician:the immediate care <strong>of</strong> the acutely ill medical patient andthe longer-term management <strong>of</strong> some <strong>of</strong> these <strong>patients</strong>.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 21


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>The general physician needs the same core acute careskills as the acute physician and these have beendiscussed previously. The acute component <strong>of</strong> a generalphysician’s work is highly significant and, <strong>with</strong> thedevelopment <strong>of</strong> acute <strong>physicians</strong> <strong>working</strong> on the AMUduring the day, this work is increasingly taking placeoutside the normal <strong>working</strong> day. In 2004, the RCPrecommended that every district general hospital(DGH) should have a minimum <strong>of</strong> three acute<strong>physicians</strong>. Given this workforce, even in a hospitalneeding only one physician involved in the acutemedical intake, more than half <strong>of</strong> the 24-hourconsultant cover for the intake will still need to beprovided by general <strong>physicians</strong>. This situation will <strong>of</strong>course vary where hospitals have larger numbers <strong>of</strong>admissions or more acute <strong>physicians</strong>, but it remains thecase that it is unlikely that acute <strong>physicians</strong> will benumerous enough to provide all acute medical care inthe near future.The recommendation that hospitals undertaking theadmission <strong>of</strong> acutely ill medical <strong>patients</strong> should have aconsultant physician on site for at least 12 hours per day,7 days a week applies as much to general <strong>physicians</strong>when they are supervising the acute medical intake as itdoes to acute <strong>physicians</strong>. As out-<strong>of</strong>-hours activity ispredictable work, it should be recognised as such in theconsultant’s job plan and may attract compensatoryperiods<strong>of</strong>timeawayfromwork.Inpatient workThe development <strong>of</strong> the medical specialties has led tomany <strong>patients</strong> admitted <strong>with</strong> single organ disordersbeing transferred to specialist care as soon as ispracticable, because there is evidence that the outcomefor such <strong>patients</strong> is better under specialist care ratherthan generalist care. There remain, however, many<strong>patients</strong> whose presentations do not meet the localcriteria for specialist care and these <strong>patients</strong> remainunder the care <strong>of</strong> general <strong>physicians</strong>. In practical terms,only a relatively small number <strong>of</strong> hospitals can <strong>of</strong>fer carein all 30 medical specialties. Most DGHs will be able toprovide specialist care in the major specialties <strong>of</strong>cardiology, gastroenterology, geriatric medicine,diabetes and endocrinology, and respiratory medicine,together <strong>with</strong> rheumatology and haematology. It is,however, unlikely that a typical DGH will havespecialists in neurology, renal medicine or infectiousdiseases based in the hospital. In the absence <strong>of</strong> thesespecialist services locally, care for <strong>patients</strong> <strong>with</strong>disorders in these specialties must be delivered bygeneral <strong>physicians</strong>. In addition, the high frequency <strong>of</strong>some cardiac and respiratory conditions is such that all<strong>patients</strong> <strong>with</strong> these relatively common disorders will notreceive specialist care when the severity <strong>of</strong> theseconditions is mild. These <strong>patients</strong> too will remain underthe care <strong>of</strong> general <strong>physicians</strong>. Lastly, it must beremembered that specialist care has been shown to bebeneficial where the patient has a single disorder. Thesame may not be true when <strong>patients</strong> have manycomorbidities, as is the case in elderly <strong>patients</strong> whomake up much <strong>of</strong> the intake. Such <strong>patients</strong> <strong>of</strong>ten have anumber <strong>of</strong> conditions including frailty and dementia. 5For all these reasons, there is a need to maintain<strong>physicians</strong> <strong>with</strong> the relevant skills to be able to care forthese groups <strong>of</strong> <strong>patients</strong>.7 Opportunities for integrated careGood <strong>working</strong> relationships between acute medicalservices and social care services are essential if <strong>patients</strong>are to avoid inappropriate or unduly prolonged stays inhospital. Early discharge can be facilitated by outreachservices from the hospital into the community, such as‘hospital at home’ schemes for <strong>patients</strong> <strong>with</strong> chronicobstructive pulmonary disease. Elderly <strong>patients</strong> canbenefit from the services <strong>of</strong> a hospital-basedre-ablement team or falls service <strong>working</strong> <strong>with</strong> the localsocial care services.8 Workforce requirements for acuteinternal medicineIn 2004, the RCP recommended that there should be acore group <strong>of</strong> acute <strong>physicians</strong> in every acute hospital totake primary responsibility for the organisation <strong>of</strong> theacute medicine service and the management <strong>of</strong> AMU.The recommendation was for at least three acute<strong>physicians</strong> in every acute hospital by 2008. 1Subsequently the Working Group on Acute and InternalMedicine, 26 set up by the Joint Committee on HigherMedical Training (JCHMT), reported that a workforce<strong>of</strong> three acute <strong>physicians</strong> per acute hospital wouldrequire over 600 new consultant posts in the specialty <strong>of</strong>AIM. The 2006 census <strong>of</strong> consultant <strong>physicians</strong> 27 foundthat there were 140 acute <strong>physicians</strong> in post at that time.By 2011, this number had increased to 295 28 but wasstill well short <strong>of</strong> the 2004 recommendation. Moreover,out <strong>of</strong> the 155 consultant appointments advertised inEngland and Wales in 2009, 60 were either cancelled orno appointment was made. This rate <strong>of</strong> 60% specialistsavailable suggests a shortage <strong>of</strong> acute medicine22 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Acute internal medicine and general internal medicineCertificate <strong>of</strong> Completion <strong>of</strong> Training (CCT) holders t<strong>of</strong>ill consultant posts and supports the case for moretraining numbers in AIM, either as new posts or as postconversions. Despite these problems, AIM has remainedthe fastest growing medical specialty in the past 5 years.A workforce <strong>of</strong> three acute <strong>physicians</strong> per acute hospitalis clearly not able to provide all the consultant inputrequired to manage the acute medical intake, and in thissituation there will still be a need for consultant<strong>physicians</strong> <strong>with</strong> specialist interests to be involved in theacute take. Some acute hospitals have, however,demonstrated their intention to employ larger numbers<strong>of</strong> acute <strong>physicians</strong>, <strong>with</strong> groups <strong>of</strong> six or seven beingappointed. If this trend is followed, then an average <strong>of</strong> 6acute <strong>physicians</strong> in each acute hospital would need aworkforce <strong>of</strong> over 1,300 acute <strong>physicians</strong>, but the needfor the continued involvement <strong>of</strong> other <strong>physicians</strong> in theacute take would be reduced and acute <strong>physicians</strong>trained in both AIM and GIM could take part in thelonger-term care <strong>of</strong> in<strong>patients</strong>. This would, however,demand even more training numbers in AIM.In planning workforce requirements, a consultantphysician should be expected to spend an average <strong>of</strong> 15minutes reviewing each patient after their formalassessment. 1,29 This should allow time for theconsultant on call to assess each new patient, review thecase and relevant documentation and talk to relatives.To this should be added time for opportunist teachingand the assessment <strong>of</strong> trainees using the ACAT.Time must also be allowed for the review <strong>of</strong> existingshort-stay <strong>patients</strong> on the AMU on post-take rounds.Thus in a typical extended <strong>working</strong> day, the consultanton call should be expected to review no more than 32new <strong>patients</strong>.Where attendances at the AMU are likely to exceed 32per 24 hours, there should be more than one consultanton duty and the number <strong>of</strong> consultants involved dailyon the AMU should reflect pro rata the number <strong>of</strong><strong>patients</strong> expected to attend. 29 <strong>Consultant</strong> work programme/specimenjob planThe models recommended in Tables 1 and 2 should beregarded as standard <strong>with</strong> respect to the activities <strong>of</strong> aconsultant in acute medicine but may be altered byagreement according to local need.Table 1 Acute physician <strong>with</strong> no additional special interestActivity Workload per session SessionsDirect patient careAcute medical unit ward rounds or hot review sessionsRapid access clinicsAmbulatory care sessionsInvestigational sessions – eg endoscopyOther specialty sessionsSupporting pr<strong>of</strong>essional activities (SPAs)Up to 32 new <strong>patients</strong> per 24 hours6 new or 12 old <strong>patients</strong>VariableVariableVariable⎫⎪⎬6.5 sessions in total⎪⎭2.5 sessionsTable 2 Acute physician <strong>with</strong> a major additional special interest, including general internal medicineActivity Workload per session SessionsDirect patient careAMU ward rounds or hot review sessionsRapid-access clinicsAmbulatory care sessionsSecond specialtySupporting pr<strong>of</strong>essional activities (SPAs)Up to 32 new <strong>patients</strong> per 24 hours6 new or 12 old <strong>patients</strong>Variable⎫⎪⎬4 sessions in total⎪⎭3.5 sessions2.5 sessionsC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 23


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>All work programmes should conform to the RCP’schecklist for consultant job descriptions. 3010 Key points for commissionersAcute medical services1 Hospitals providing assessment and admission <strong>of</strong>acutely ill medical <strong>patients</strong> should have AMUs orequivalent facilities (RCP, SAM, NCEPOD).2 AMUs should have defined medical and nursingleads, written operational policies and regular auditsincluding 24-hour mortality, 7-day readmission anddirect discharge rates.3 The consultant physician on call should be on site forat least 12 hours per day, 7 days a week, and shouldhave no other duties scheduled during this time.4 The consultant on call should review <strong>patients</strong> assoon as possible after their formal assessment hasbeen completed. During the <strong>working</strong> day this reviewshould take place <strong>with</strong>in 6–8 hours <strong>of</strong> the patient’sadmission to the AMU. Patients admittedovernight should receive a consultant review <strong>with</strong>in14 hours.5 The acute medicine service should <strong>of</strong>fer alternativesto admission including rapid access outpatientclinics and an ambulatory emergency care service(RCP, SAM).General medical services1 Hospitals have a responsibility to provide enoughexperienced medical and nursing practitioners todeliver prompt high-quality care to all their <strong>patients</strong>in facilities appropriate to their <strong>patients</strong>’ needs. Noprovider should provide any service that does notcomply <strong>with</strong> fundamental standards <strong>of</strong> service.2 It should be evident that general <strong>physicians</strong> haveused some <strong>of</strong> their CPD to acquire and maintainexpertise in the management <strong>of</strong> <strong>patients</strong> whosedisorders are not appropriate for specialist care<strong>with</strong>in their hospitals. This could include, forinstance, neurological, renal or infectious diseases.3 A consultant physician should visit every medicalward daily, including at weekends, to addressproblems <strong>of</strong> <strong>patients</strong> already in hospital and shouldbe supported in this task by junior medical staff(RCP). This should be a priority duty in the firsthour <strong>of</strong> the <strong>working</strong> day – ‘golden hour’ review.4 Rapid access to imaging, laboratory tests and otherdiagnostic and support services is crucial and shouldbe available 7 days a week to inform treatment andfacilitate discharge (RCP, RCPEdin).5 Patientobservationsonallwardsshouldincludecontinuous evaluation by NEWS, <strong>with</strong> clearprotocols in place to escalate or redefine care on thebasis <strong>of</strong> these scores.References1 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Acute medicine: making itwork for <strong>patients</strong>. Report <strong>of</strong> a <strong>working</strong> party. London: RCP,2004.2 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Acute medical care: the rightperson, in the right setting – first time. Report <strong>of</strong> a <strong>working</strong>party. London: RCP, 2007.3 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK.The physician <strong>of</strong> tomorrow. Curriculum for generalinternal medicine (acute medicine). London: RCP, 2007.4 National Confidential Enquiry into Patient Outcome andDeath. Emergency admissions: a journey in the rightdirection? A report <strong>of</strong> NCEPOD. London: NCEPOD, 2007.5 Moore S, Gemmell I, Almond S, et al. Impact <strong>of</strong> specialistcare on clinical outcomes for medical emergencies. ClinMed 2006;6:286–93.6 Society for Acute Medicine. Recommendations for medicalassessment (admission) units.Report<strong>of</strong>a<strong>working</strong>party.SAM, 2003.7 NHS Institute for Innovation and Improvement. Thedirectory <strong>of</strong> ambulatory emergency care for adults,3rdedition. London, 2012. www.institute.nhs.uk/option,com joomcart/Itemid,194/main page,document productinfo/products id,181.html8 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians <strong>of</strong> Edinburgh. UK consensusstatement on acute medicine. Edinburgh: RCP Edin, 2008.www.rcpe.ac.uk/clinical-standards/standards/finalstatement-rcpe-consensus-conference-on-acutemedicine-nov-2008.pdf[Accessed 20 March 2013].9 Society for Acute Medicine. Guidelines for physiotherapyin medical assessment units. Report<strong>of</strong>a<strong>working</strong>party.SAM, 2004.10 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Interface <strong>of</strong> accident andemergency and acute medicine.Report<strong>of</strong>a<strong>working</strong>party.London: RCP, 2002.11 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Interface between acutegeneral medicine and critical care. Report <strong>of</strong> a <strong>working</strong>party. London: RCP, 2002.12 Houghton M. Acute medicine – an alternative take. ClinMed 2011;11:26–7.13 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Council statement on acutemedical care out <strong>of</strong> hours. London: RCP, 2011.http://pressrelease.rcplondon.ac.uk/Archive/2010/Patients-deserve-better-out-<strong>of</strong>-hours-care-says-RCP-President [Accessed 20 March 2013].14 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. National Early WarningScore (NEWS): Standardising the assessment <strong>of</strong> acuteillness severity in the NHS. Report <strong>of</strong> a <strong>working</strong> party.24 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Acute internal medicine and general internal medicineLondon: RCP, 2012. http://tfinews.ocbmedia.com[Accessed 20 March 2013].15 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Acute care toolkit 4: 12-hour,7-dayconsultantpresenceontheacutemedicalunit.www.rcplondon.ac.uk/sites/default/files/documents/acutecare-toolkit-4.pdf.16 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Continuity <strong>of</strong> care for medicalin<strong>patients</strong>: standards <strong>of</strong> good practice. London: RCP, 2004.http://bookshop.rcplondon.ac.uk/contents/pub70-420ba100-bfae-46e4-9eb4-9048d120acba.pdf [Accessed20 March 2013].17 British Medical Association. Safe handover: safe <strong>patients</strong>.London: BMA, 2004. https://bma.org.uk/-/media/Files/PDFs/Practical%20advice%20at%20work/Contracts/safe%20handover%20safe%20<strong>patients</strong>.pdf18 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Acutecaretoolkit1:Handover. London: RCP, 2011. www.rcplondon.ac.uk/sites/default/files/acute-care-toolkit-1-handover.pdf[Accessed 20 March 2013].19 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Acutecaretoolkit2:High-quality acute care. London: RCP, 2011. www.rcplondon.ac.uk/sites/default/files/acute-care-toolkit-2-high-quality-acute-care.pdf20 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Acutecaretoolkit5:Teachingon the acute medical unit. London: RCP, 2012.www.rcplondon.ac.uk/resources/acute-care-toolkit-5-teaching-acute-medical-unit [Accessed 20 March 2013].21 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Governance in acute generalmedicine. Recommendations from the Committee onGeneral (Internal) Medicine <strong>of</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong>Physicians. London: RCP, 2000.22 West Midlands Quality Review Service and the Societyfor Acute Medicine. Quality Standards for Acute MedicalUnits (AMUs) SAM, 2012. http://www.acutemedicine.org.uk/index.php?option=com docman&task=docdownload&gid=116&Itemid=2123 Society for Acute Medicine. Clinical quality indicators foracute medical units (AMUs). SAM, 2011. www.acutemedicine.org.uk/images/stories/pdf/clinical qualityindicators for acute medical units v18.pdf [Accessed20 March 2013].24 National Institute for Health and Care Excellence. Auditcriteria – acutely ill <strong>patients</strong> in hospital. Clinical guideline50. London: NICE, 2007. http://guidance.nice.org.uk/CG50/AuditSupport/doc/English [Accessed20 March 2013].25 Intensive Care Society. Levels <strong>of</strong> critical care for adult<strong>patients</strong>. London: ICS, 2009.26 Joint Committee on Higher Medical Training. Acutemedicine training in the UK: ‘the way forward’. Report <strong>of</strong>the Working Group on Acute and General Medicine.London: JCHMT, 2006.27 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK.Census <strong>of</strong> consultant <strong>physicians</strong> in the UK, 2006: data andcommentary. London: RCP, 2007.28 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK.Census <strong>of</strong> consultant <strong>physicians</strong> and medical registrars inthe UK, 2011: data and commentary. London: RCP, 2013.www.rcplondon.ac.uk/sites/default/files/census <strong>of</strong>consultant <strong>physicians</strong> and medical registrars in the uk2011 1.pdf29 Herring R, Desai T, Caldwell G. Quality and safety at thepoint <strong>of</strong> care: how long should a ward round take? ClinMed 2011;11:20–2.30 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Checklist for consultant jobdescriptions. London: RCP, 2010.www.rcplondon.ac.uk/resources/pr<strong>of</strong>essionalism/AAC[Accessed 20 March 2013].C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 25


2 Specialties AllergyAllergyDr Pamela Ewan <strong>Consultant</strong> allergistDr Shuaib Nasser <strong>Consultant</strong> allergist1 Description <strong>of</strong> the specialtyAllergy is a non-organ-based specialty, <strong>with</strong> its owntraining programme and Certificate <strong>of</strong> Completion <strong>of</strong>Training (CCT). The allergist provides expertise indiagnosis and management <strong>of</strong> allergy that is different,and complementary to, services <strong>of</strong> other specialties.Allergic disorders are common and increasing inprevalence. They cause significant impairment <strong>of</strong>quality <strong>of</strong> life and considerable direct cost to theNHS. 1,2 The need is to identify or exclude allergy as acause <strong>of</strong> disease, eg an acute allergic reaction, or in achronic disorder such as asthma, rhinitis, eczema orurticaria; and to provide management. Allergydiagnosis and avoidance can prevent further episodesor reduce disease. This results in substantial healthcareimpact, reducing healthcare costs and improvingquality <strong>of</strong> life for the patient.There has been a documented rise in allergic diseaseover the lasts three decades in numbers, severity andcomplexity, eg admissions for anaphylaxis have risensevenfold in 10 years, 1,2 and nut allergy, previously rare,now occurs in 2% <strong>of</strong> children and persists to adulthood.Food and drug allergy and angioedema are common.New allergies are also appearing. The allergy epidemichas created a new and substantial demand for consultantallergists, not previously addressed by the NHS.There are a small number <strong>of</strong> specialist allergy servicesrun by academic or NHS consultant allergists. Inresponse to demand, some organ-based specialists,immunologists and paediatricians provide part-time orlimited allergy services in addition to their main service,which is only a partial response to patient need. Formany <strong>patients</strong>, however, there is an unmet need. Thereis inadequate access to care, suboptimal healthcaredelivery and, consequently, unnecessary cost to the NHSin avoidable disease. 3,4A <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP) report proposed arational approach to improve patient care in response tocurrent inequalities and the developing allergyepidemic. 3 Key to services is development <strong>of</strong> at least onemajor allergy centre in each region, staffed by adult andpaediatric allergists. This requires increased numbers <strong>of</strong>allergy consultants and allergy trainees. Such aninvestment would provide the infrastructure andexpertise for the development <strong>of</strong> services throughoutthe region and support education in primary andsecondary care. A House <strong>of</strong> Commons HealthCommittee inquiry into allergy services endorsed theRCP report, recommending the development <strong>of</strong>national allergy services and commissioning <strong>of</strong> allergycentres. 4 In England, a Department <strong>of</strong> Health (DH)review recognised the need for allergy services. 5 Pivotalto service development and patient care is the need totrain more allergists.Who are the <strong>patients</strong>?NumbersAllergic disease is one <strong>of</strong> the most common diseases anda major public health problem. About 20 million peopleintheUKhaveadiseasewhereallergymaybeinvolved.Around 3.5–7 million require the care <strong>of</strong> a specialistallergist. 5DisordersDisorders commonly coexist. Some may beimmunoglobulin E (IgE)- or non-IgE-mediated: asthma rhinitis, conjunctivitis, rhino–sinusitis, nasal polyps eczema anaphylaxis urticaria angioedema glottal oedema food allergy, eosinophilic enteropathies food intolerance drug allergy latex allergy venom allergy mast-cell disorders occupational allergy.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 27


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Allergies in childrenForty per cent <strong>of</strong> children have allergies. Owing to ashortage <strong>of</strong> paediatric allergists, children are <strong>of</strong>ten seenby adult allergists.Main disease patternsWide-ranging natureAllergic disease is wide ranging (as listed above).Allergists also deal <strong>with</strong> non-IgE-mediated disorders,including rhinitis, angioedema and anaphylaxis.ComplexityMultiple disorders and multiple allergies are commonin an individual, eg asthma, rhinitis, eczema, foodallergy and anaphylaxis coexist. There are cross-reactingallergens.New allergiesNew kinds <strong>of</strong> allergies are emerging, eg foods, drugs anddiagnostics.ProgressionIn children, allergies develop progressively. Much <strong>of</strong> thispersists to adulthood.SeverityA proportion <strong>of</strong> <strong>patients</strong> has severe or life-threateningdisease or disease impairing schooling or ability to work(eg anaphylaxis, airway oedema or multi-systemallergy).2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceThere is a specialist definition for allergy (Specialisedservices national definitions set, definition no 17). 6 Thepurpose is to identify the activity that should beregarded as specialised and hence <strong>with</strong>in the remit <strong>of</strong>PCT collaborative commissioning. However, there islack <strong>of</strong> recognition by commissioners <strong>of</strong> the need forallergy commissioning. This occurs around theestablished specialist allergy centres but is lacking inmany parts <strong>of</strong> the country. Allergy is a specialtyrecognised for specialist commissioning by the DH inEngland.Specialist servicesThese provide high-throughput, comprehensive,full-time services led by allergists <strong>with</strong> the expertise todeal <strong>with</strong> a range <strong>of</strong> allergic diseases. These servicestypically <strong>of</strong>fer: one-stop diagnosis and management;complex investigation requiring day-case service, eg fordrug or food allergy; immunotherapy; and anti-IgEtherapy. There are only a small number <strong>of</strong> theseservices, but each sees large numbers and more complex<strong>patients</strong> (eg ∼5,000 pa).Subspecialty servicesOther clinics are part time and provided by consultantsin other specialties, most <strong>of</strong> whom <strong>of</strong>fer a limitedspectrum <strong>of</strong> diagnostic and treatment facilities. 5There is a geographical inequality and national shortage<strong>of</strong> doctors <strong>with</strong> allergy expertise. GPs dealing <strong>with</strong> thebrunt <strong>of</strong> allergic disease have limited training and accessto specialist advice.Current services and proposals for allergy care areoutlined in the RCP report 3 and the British Society forAllergy & Clinical Immunology (BSACI) and NationalAllergy Strategy Group (NASG) submissions to theDH. 5,7,8 The RCP proposed the following: Tier 1 – simpler allergic diseases managed inprimary care or by self care (allergy diagnosis <strong>of</strong>tennot required) Tier 2a – consultant allergists in teaching hospitalsand district general hospitals to provide secondarycare Tier 2b – other specialists <strong>with</strong> an interest in allergy(immunologists; dermatologists; respiratory<strong>physicians</strong>; ear, nose and throat (ENT) specialists;paediatricians) to contribute to secondary care Tier 3 – regional allergy centres to managespecialised tertiary problems and provide localsecondary care.This model has been developed subsequently in papersfrom BSACI identifying the burden <strong>of</strong> disease andreferral pathways. 7,8Sources <strong>of</strong> referral from primary, secondaryand tertiary levelsReferral is mainly direct to a specialist centre from apatient’s GP (>80%) but from a wide (<strong>of</strong>ten regional)catchment. Patients are also referred from otherservices, eg respiratory, dermatology and anaesthetics.Locality-based and/or regional servicesMost major specialist services provide a regional andlocal service because <strong>of</strong> few providers in each region.28 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties AllergyDrug allergy and anaphylaxis during anaesthesia requireexpertise and high throughput and should be part <strong>of</strong> aregional service.Community models <strong>of</strong> careClose links between specialists and GPs are needed <strong>with</strong>early discharge and supported care in the community.Because <strong>of</strong> the lack <strong>of</strong> specialists, it has not been costeffective to develop outreach services. Specialist allergynurses from major centres could be commissioned toprovide diagnostic skin test services to local GPs. Pleasenote that consortia are not in place in Wales andNorthern Ireland.Complementary servicesA wide range <strong>of</strong> alternative allergy diagnostic tests andtreatments are available to the public but these are notscientifically based and cannot be recommended.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong> and how you do itGood allergy care requires accurate allergy diagnosisthrough identification or exclusion <strong>of</strong> allergic triggers.Essential are a detailed allergy history and skin-pricktests. Intradermal and challenge testing may be requiredas well. Management includes avoidance advice,training in self-use <strong>of</strong> rescue medication in case <strong>of</strong>inadvertent acute reactions and medication to controlchronic conditions. Monitoring is required in somedisorders.Involving <strong>patients</strong> in their treatmentInforming and involving <strong>patients</strong> is a crucial aspect <strong>of</strong>effective allergy care. Patients are trained in: avoidance<strong>of</strong> triggers (eg foods, drugs) to prevent or reducedisease (eg anaphylaxis, asthma, eczema);self-administration <strong>of</strong> drugs in self-management plansfor acute attacks; and prophylactic treatment forpredictable allergen exposure. Early whole-systemeffective intervention prevents the development <strong>of</strong>chronic illness.Education and self careThis is a major part <strong>of</strong> allergy care (see above).Chronic conditionsMany allergic conditions are chronic but controllable(asthma, rhinitis, eczema) or avoidable (food ordrug allergy, anaphylaxis). These require long-termcare, which can be shared <strong>with</strong> or transferred toprimary care.The role <strong>of</strong> the carerInvolvement <strong>of</strong> the carer is vital in terms <strong>of</strong> food andother allergies. When injected adrenaline is required,partners/parents must be trained to administer this.Patient support groupsPatientgroups–AllergyUKandtheAnaphylaxisCampaign – are members <strong>of</strong> NASG 8 and play a vital rolein providing support and information in the absence <strong>of</strong>an adequate NHS service. The most common reason forcalls to their helplines is difficulty in being referred to anallergy clinic or finding one able to deal <strong>with</strong> thepatient’s problem.Access to informationSpecialist centres have a wide range <strong>of</strong> patient literature,as do BSACI 7 and patient charities.Availability <strong>of</strong> clinical records/resultsThese can be supplied according to patient preference.Role <strong>of</strong> expert patientAllergy management involves training <strong>patients</strong> toself-manage.Communication <strong>with</strong> <strong>patients</strong>Good communication is essential to elicit the allergyhistory and explain the diagnosis and management.4 Interspecialty and interdisciplinaryliaisonMultidisciplinary team<strong>working</strong>The following groups fulfil important roles in the team: allergy specialist nurses dietitians (adult and paediatric) trained in allergy pharmacy and drug information services.Working <strong>with</strong> other specialists For a minority <strong>of</strong> <strong>patients</strong>, allergists liaise <strong>with</strong>respiratory <strong>physicians</strong>, dermatologists,immunologists, ENT consultants or paediatricians.These consultants may refer <strong>patients</strong>; somecontribute to allergy care.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 29


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> Most allergy diagnosis is done by skin testing. Animmunology laboratory service is required. A paediatrician is identified as a contact where<strong>physicians</strong> dealing <strong>with</strong> adults provide paediatricallergy services. Other specialists include community paediatriciansand nurses (for children at risk <strong>of</strong> anaphylaxis) andoccupational health <strong>physicians</strong> (for occupationalallergies and vaccination reactions).Working <strong>with</strong> GPs and GPs <strong>with</strong> a special interest(GPwSIs)There is no formal GPwSI curriculum in allergy, but asmall number <strong>of</strong> GPs work in allergy departments.Extensive GP liaison occurs as a result <strong>of</strong> referrals andshared care.Other specialty activity beyond local servicesThere are regional and national services for drug allergyand anaphylaxis during anaesthesia. Joint ENT/allergyclinics exist for selected <strong>patients</strong>.5 Delivering a high-quality serviceWhat is a high-quality service?<strong>Consultant</strong> allergists should have completed the allergytraining programme (allergy CCT). A minimum <strong>of</strong> tw<strong>of</strong>ull-time consultant allergists are required <strong>with</strong>appropriate support staff.The following resources are recommended foroutpatient, day-case and inpatient settings.Outpatient services a comprehensive, high-volume service ableto diagnose and manage all types <strong>of</strong> allergicdisease skin-prick test primary investigation defined and integrated clinic facilities forout<strong>patients</strong> and day cases immediate access to drugs and equipment fortreatment <strong>of</strong> anaphylaxis.Day-case investigation and immunotherapy agreed protocols and approach to diagnosis sufficient caseload to ensure expertise andcontinuing standards <strong>of</strong> care; dedicated sessions fordrug challenge and immunotherapy at least weekly facilities to store and prepare drugs and conductchallenge tests team approach.In<strong>patients</strong> rapid consultation service.Work to maintain and improve the quality <strong>of</strong> careService developments to deliver improved patientcare Nut allergy managed in specialist allergy clinicsreduces morbidity. ENT surgery can be avoided by treatment <strong>of</strong> rhinitisby allergists. Immunotherapy reduces chronic disease, drug useand improves quality <strong>of</strong> life. Challenge testing enables diagnosis <strong>of</strong> drug and foodallergy. Liaison <strong>with</strong> community paediatricians improvescare for children at risk <strong>of</strong> anaphylaxis. A single consultation <strong>with</strong> an allergist is moreeffective than multiple referrals to organ-basedspecialists. Development <strong>of</strong> new therapies, eg anti-IgE, anddesensitisation for peanut allergy.Education and trainingThe allergist may act as educational supervisor forallergy trainees and has a role in the education andsupport <strong>of</strong> colleagues in primary care and otherspecialist services in their region. The centre willnetwork <strong>with</strong> these other providers to enhance allergyprovision in the region. This encompasses clinicalgovernance, pr<strong>of</strong>essional self-regulation, andcontinuing pr<strong>of</strong>essional development (CPD).Research – clinical studies and basic scienceThere is a strong tradition <strong>of</strong> academic allergy in theUK. Most allergy centres have developed throughacademic funding. Academic allergists make animportant contribution to allergy <strong>with</strong>in NHS truststhrough service delivery, service development, guidelinedevelopment, clinical research and training. Basic andclinical allergy research in the UK is internationallyrecognised for excellence and has led to improvementsin patient care.Specialty and national guidelines and auditTable 1 lists some useful guidelines and audits for thisspecialty.A national audit <strong>of</strong> venom immunotherapy revealedvariable practice; BSACI guidelines were subsequentlyproduced. 7 An audit <strong>of</strong> asthma deaths suggested allergywas a cause but that this had not been addressed in life.30 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties AllergyTable 1 Guidelines and audits for allergy servicesOrganisation Guidance WeblinkBSACI Standards <strong>of</strong> Care CommitteeNICEGuidelines for specialists (including rhinitis,urticaria, angioedema, anaphylaxis during generalanaesthesia, drug allergy, egg allergy, venomimmunotherapy); guidelines for primary careDiagnosis <strong>of</strong> food allergy in children andyoung peopleAnaphylaxis (in development)Venom immunotherapy (in development)www.bsaci.orghttp://guidance.nice.org.uk/CG116<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Paediatrics & ChildHealth (RCPCH)Care pathways for children <strong>with</strong> allergyIncludes:www.rcpch.ac.uk/allergy/anaphylaxiswww.rcpch.ac.uk/allergy/foodallergyOrganisation Audit WeblinkBSACIEastern Region InquiryVenom immunotherapyAsthma deathsQuality tools and frameworksQuality <strong>of</strong> care requires clinical expertise. The history isparamount and reliance on tests alone is a source <strong>of</strong>misdiagnosis. Allergy services are sometimes providedby those <strong>with</strong> little training, so standards vary. Allergyplays an important role in various diseases, eg asthma,but this aspect is <strong>of</strong>ten ignored. BSACI guidelines are agood source <strong>of</strong> developing and supporting standards.Allergy centres should evaluate diagnostic methods andconduct clinical research.6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialty An allergist works full time in allergy. This specialtyis outpatient and day-case based, <strong>with</strong> minimalinpatient component. NHS consultants typically have five clinics a week,comprising general allergy and some specialisedclinics or day-case sessions. Day-case work includes complex investigation,diagnostic challenge tests and desensitisation andanti-IgE therapy. Telephone or written advice is also provided <strong>with</strong>outseeing the patient; consultants act as an educationalresource for GPs. Outpatient work is complex and each consultationtakes time. This is because many <strong>patients</strong> havemultiple allergic disorders, which are usuallydealt <strong>with</strong> in a single consultation, so a detailedallergy history is critical to accurate diagnosis. Thisrequires team approach and a series <strong>of</strong> diagnosticand management components, eg allergenavoidance, self-management plans, training to useadrenaline auto-injectors and organisation <strong>of</strong> schooltraining. Day-case work involves a series <strong>of</strong> diagnostic steps,over 4–6 hours, <strong>with</strong> the risk <strong>of</strong> anaphylaxis. There is a heavy burden in information provisionandcomplexity<strong>of</strong>letters,egindrugorfoodallergy. A centre might see 5,000–8,000 <strong>patients</strong> <strong>with</strong> asignificant component <strong>of</strong> day cases per annumdepending on staffing; 100% <strong>of</strong> the work is specialtyand >95% outpatient/day-case based. Theconsultant supervises the work <strong>of</strong> other members <strong>of</strong>the team.Inpatient workAllergists do not deal <strong>with</strong> acute medicine. They do,however, provide a consultation service for in<strong>patients</strong>,eg <strong>with</strong> drug allergy.Outpatient work General allergy clinics: new to follow-up patientratios vary <strong>with</strong> the complexity <strong>of</strong> referrals andservice provided, eg four new <strong>patients</strong> plus tworeview <strong>patients</strong> per doctor. Additional time isrequired for teaching and reviewing <strong>patients</strong> <strong>of</strong>trainees.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 31


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>2 Gupta R, Sheikh A, Strachan DP, Andersen HR. Theburden <strong>of</strong> allergic disease in the UK. Clin Exp Allergy2004;34(4):520–6.3 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Allergy: the unmet need. Ablueprint for better patient care.Areport<strong>of</strong>the<strong>Royal</strong><strong>College</strong> <strong>of</strong> Physicians <strong>working</strong> party on the provision<strong>of</strong> allergy services in the UK. London: RCP, 2003(pp 1–93).4 House <strong>of</strong> Commons Health Committee. The provision <strong>of</strong>allergy services. London: Stationery Office, 2004.5 Department <strong>of</strong> Health. Areview<strong>of</strong>servicesforallergy. Theepidemiology, demand for and provision <strong>of</strong> treatment andeffectiveness <strong>of</strong> clinical interventions. Gateway ref 6835.London: DH, 2006.6 Department <strong>of</strong> Health. Specialised services nationaldefinitions set. Specialised services for allergic diseases (allages) – definition no. 17, 3rd edn. London: DH, 2010.7 British Society for Allergy & Clinical Immunology.www.bsaci.org8 National Allergy Strategy Group. www.nasguk.orgNote to readers: This chapter has not been updated for the revised 5th edition 2013. The text has been reproduced from the 2011 edition.34 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Audiovestibular medicineAudiovestibular medicineDr Breege Mac Ardle FRCP FRCPCH <strong>Consultant</strong> in audiovestibular medicineDr Sebastian Hendricks FRCPCH MSc <strong>Consultant</strong> audiovestibular physicianand paediatricianDr Dolores Umapathy FRCP MSc <strong>Consultant</strong> in audiovestibular medicine1 Description <strong>of</strong> the specialtyAudiovestibular medicine (AVM) is the specialtyconcerned <strong>with</strong> prevention, investigation, diagnosis andmanagement <strong>of</strong> adults and children <strong>with</strong> disorders <strong>of</strong>hearing, balance and tinnitus. 1 Some specialists alsoinclude developmental disorders <strong>of</strong> speech andlanguage. This is a small specialty <strong>with</strong> an unevendistribution across the UK. There is an unmet need thatis only partially met by other specialties.Audiovestibular <strong>physicians</strong> (AVPs) play a key role in themultidisciplinary team (MDT) involved <strong>with</strong>assessment and management <strong>of</strong> <strong>patients</strong>. Competenciesin general internal medicine, paediatrics and childhealth underpin the practice <strong>of</strong> AVM. Knowledge<strong>of</strong> the pathophysiology <strong>of</strong> systemic, neurologicaland otological diseases and disorders that affectthe audiovestibular system throughout life isessential.Who are the <strong>patients</strong>?Hearing loss and dysequilibrium are widespread in theUK adult population and will increase <strong>with</strong> thechanging demographics: One third <strong>of</strong> those over 60 years have a hearing loss<strong>of</strong> 25 decibels or more. Symptoms <strong>of</strong> dizziness or imbalance areexperienced by 30% <strong>of</strong> the population by the age <strong>of</strong>65 years. 1 Balanceproblemsarethemostcommoncause<strong>of</strong>presentation to primary care in <strong>patients</strong> over 74years <strong>of</strong> age. 2 AVPs are involved in complex cases <strong>of</strong> hearing lossand assessments for cochlear implants. Many <strong>patients</strong> have other complex needs, eg 45% <strong>of</strong>deaf adults under the age <strong>of</strong> 60 have additionaldisabilities. 3 Tinnitus affects up to 20% <strong>of</strong> the population, <strong>with</strong>5% describing the complaint as troublesome, whilefor 1% it is severe enough to have a significant effecton their quality <strong>of</strong> life. 3Balance disorders are less common in children, affectingonly 8%, 4 but may be difficult to assess and manage. Approximately 1:1,000 children are born <strong>with</strong>bilateral permanent hearing impairment each year 5and 2:1,000 will have a unilateral hearingimpairment. 6 25%<strong>of</strong>allchildrenuptotheage<strong>of</strong>4yearssufferfrom otitis media <strong>with</strong> effusion at any one time 7 and80% <strong>of</strong> children under 8 years <strong>of</strong> age haveexperienced temporary deafness due to glue ear. 8Current best management <strong>of</strong> this includes the use <strong>of</strong>amplification rather than surgery. 9 Approximately 10% <strong>of</strong> children have some degree <strong>of</strong>auditory processing disorder. 10 Approximately 6% <strong>of</strong> children have speech andlanguage disorders. 11Main disease patternsPermanent childhood hearing impairment can becongenital or acquired and syndromic ornon-syndromic and is <strong>of</strong>ten accompanied by othersymptoms and disabilities. AVPs are involved in themedical diagnosis (from newborn hearing screeningand beyond), aetiological investigation and(re)habilitation. Hundreds <strong>of</strong> conditions are involvedand it is important for families to fully understand theirchild’s problem(s). Other associated conditions arementioned earlier.Balance disorders including those <strong>of</strong> vestibular originprovide the bulk <strong>of</strong> most AVPs’ adult-patient load but<strong>patients</strong> <strong>with</strong> complex, progressive, unknown orasymmetrical hearing problems and/or tinnitus are alsocommon. Conditions range from the common benignparoxysmal positional vertigo (BPPV) andmigraine-associated vertigo through to complexC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 35


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>neurological problems and systemic disease: diabetes,autoimmune disorders, syndromic disorders andvascular disease. Those <strong>with</strong> chronic balance disordersfrom whatever cause suffer significant social,occupational, emotional and economic disability.They are best managed by a team that will includeexpert physiotherapy, AVP and counselling. AVPsinvestigate causation and <strong>with</strong> the MDT manageboth children and adults <strong>with</strong> auditory processingdifficulties.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceThere are areas <strong>of</strong> the country where there are no AVPsand the service <strong>of</strong> each consultant varies. There is notypical service.AVPs are involved across primary, secondary andtertiary care. Most are employed by acute trusts. Someconsultants work in a ‘hub and spoke’ network,delivering services to neighbouring trusts on a practicalor consultative basis.Some consultants cover the whole spectrum <strong>of</strong> serviceprovision in AVM, but others may specialise inpaediatrics or adults. Subspecialty areas includecochlear implantation, auditory processing disorders,developmental neuro-otology, disorders <strong>of</strong> speech andlanguage, cleft palate, adults <strong>with</strong> learning disability,and paediatric vestibular service. Delivery ispredominantly through an MDT, which is commonlyled by an AVP, audiologist, paediatrician or otologist.Practice is primarily outpatient based <strong>with</strong> inpatientconsultation for <strong>patients</strong> admitted in other specialties;rarely, <strong>patients</strong> are admitted for intensive diagnostic orrehabilitative work. Adults and children are seen inseparate clinics in all practices.Secondary audiovestibular services provide amultidisciplinary approach in dedicated facilities andmanage the vast majority <strong>of</strong> audiovestibular problemseffectively. Approximately 20% <strong>of</strong> adult <strong>patients</strong> and67% <strong>of</strong> child <strong>patients</strong> will see more than two healthpr<strong>of</strong>essionals at any one visit, <strong>with</strong> the aim <strong>of</strong>formulating both an accurate diagnosis and a plan forrehabilitation or treatment. Appointments <strong>of</strong>ten includedetailed testing by audiologists and assessments byother pr<strong>of</strong>essionals.Tertiary services for both adults and children arehospital based and include sophisticatedneuro-otological test facilities, cochlear implantprogrammes, bone-anchored hearing aid programmes,and specialised advice and assessment in services suchas cleft palate, dual sensory loss or falls clinics.Integrated multidisciplinary care is a key feature <strong>of</strong>these services.Sources <strong>of</strong> referralFigure 1 shows the sources <strong>of</strong> referral to AVM from theprimary, secondary and tertiary levels.Locality-based and/or regional servicesSome AVPs work in district general hospitals (DGHs)and others in specialist centres where the majority <strong>of</strong>work is tertiary. There is a disproportionateconcentration <strong>of</strong> services in London and the south east,<strong>with</strong> a few consultants in the north <strong>of</strong> England, one inScotland, one in Wales and large gaps in most otherparts <strong>of</strong> the country. Different AVPs provide a regional,supra-regional or national service.The implementation <strong>of</strong> the Newborn Hearing ScreeningProgramme (NHSP) had a significant effect onpaediatric AVM <strong>with</strong> increased clinical, diagnostic andmanagement demands for <strong>patients</strong> at a much youngerage. In many areas, AVPs are involved in thecoordination and implementation <strong>of</strong> various local andnational aspects <strong>of</strong> this programme, <strong>working</strong> closely<strong>with</strong> audiologists and consultant communitypaediatricians.The long-term nature <strong>of</strong> some neuro-otological andother underlying systemic disorders means thatorganisation <strong>of</strong> transitional care services betweenpaediatric and adult services is essential.Community models <strong>of</strong> careThere are no structured AVM services for adults inprimary care, although some services for adults are nowprovided in a primary-care setting by generalpractitioners <strong>with</strong> a special interest (GPwSIs) in otology.Some AVPs have developed community-based servicesfor common problems and hub-and-spoke serviceswould support the provision <strong>of</strong> more rapid effectivecare for this group <strong>of</strong> <strong>patients</strong>.A significant proportion <strong>of</strong> paediatric audiologicalservices, including hearing surveillance programmes,are provided by second-tier community services.36 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Audiovestibular medicineHealth services forelderly peopleChild health anddevelopmentLearning disabilityservicesAudiovestibular medicineSpeech and languagetherapyNeurologyAdultsPaediatricsNewborn hearingscreening programmeAcute paediatricsGeneral medicineGPNeonatologyENTFig 1 Sources <strong>of</strong> referral to audiovestibular medicine from primary, secondary and tertiary levels.ENT = ear, nose and throat specialists; GP = general practitioners.These feed into secondary audiovestibular provisionin either the hospital or the community. Not allcommunity audiology services are led by AVPs;some may be delivered by paediatricians in childhealth who have gained additional competencies inaudiology.Successful moves <strong>of</strong> services into alternative healthcaresettings will depend largely on the provision <strong>of</strong> facilitiesand space for interdisciplinary teamwork, which is attheheart<strong>of</strong>patientcareinthisfield.Complementary servicesAVPsworkclosely<strong>with</strong>awidevariety<strong>of</strong>services.Theseinclude old age medicine, neurology, otology,paediatrics, ophthalmology, psychiatry, oncology,endocrinology, acute medicine, cardiology, speech andlanguage therapy, clinical psychology, audiology,rehabilitation services, NHSP, social work and thevoluntary sector.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareInteraction <strong>with</strong> <strong>patients</strong>The basis <strong>of</strong> all clinical work is careful history anddetailed medical examination, supported byconventional medical investigations. Selection andinterpretation <strong>of</strong> specialist assessments by otherhealthcare pr<strong>of</strong>essionals supports the physician toproduce both a diagnosis and a management plan,incorporating active treatment where appropriate.Audiovestibular disorders are <strong>of</strong>ten chronic andsuccessful management requires effectivecommunication <strong>with</strong> <strong>patients</strong> and carers/families aboutthe nature <strong>of</strong> the disorder and the possible managementoptions. Clinical activity needs to be delivered by anMDTinanacousticallyandpatient-friendlyenvironment <strong>with</strong> interpreters for both sign language(British Sign Language (BSL) and other sign support)and English as a second language, as needed.Patient-centred care AVPs are careful to provide unbiased information toenable <strong>patients</strong> and parents/carers to make informeddecisions about their investigations andinterventions. This enables the patient to have aninput in their care plan. Knowledge <strong>of</strong> and respect for the varied attitudes todeafness and disability in different ethnic andcultural groups enables informed discussion. Forexample: community attitudes to deafness thatdiffer in relation to genetic testing; disquiet in thedeaf community about the use <strong>of</strong> cochlearimplants or hearing aids; and the use <strong>of</strong> signlanguage.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 37


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> Each consultation provides an opportunity toeducate the patient and to check theirunderstanding <strong>of</strong> their condition. All members <strong>of</strong>the MDT have an important contribution to makein this area. In order to promote self-care, there should beunderstanding <strong>of</strong> the condition. Perseverance andcommitment from <strong>patients</strong> and their families areessential for successful auditory and vestibular(re)habilitation as well as compliance <strong>with</strong>pharmacological and other treatments. AVPs and the MDT have a key role in reinforcing theimportant task <strong>of</strong> parents and carers incontributing to and implementing care plans for<strong>patients</strong>. Local services for children should all have aChildren’s Hearing Services Working Group(CHSWG) in which (trained) parents participate<strong>with</strong> multiagency pr<strong>of</strong>essionals to ensuredevelopment <strong>of</strong> effective local services. Voluntary bodies, including Action for Deafness(AFD), the National Deaf Children’s Society(NDCS) and the Ménière’s Society provide easilyaccessible information for <strong>patients</strong> as well asdeveloping criteria for good practice. Information on audiovestibular disorders isavailable from websites, special libraries, and writtenmaterial produced by educational, clinical andpatient support groups. Information about relevant support groups(such as AFD, NDCS, Hearing Concern,Ménière’s Society, British Tinnitus Association(BTA), British Deaf Association (BDA), <strong>Royal</strong>Association for the Deaf (RAD), SignHealth (theNational Society for Mental Health and Deafness;previously called Sign), Council for theAdvancement <strong>of</strong> Communication <strong>with</strong> DeafPeople (CACDP), Usher’s Society, Sense and Afasicshould be readily available in outpatientdepartments. It is good practice to copy <strong>patients</strong> and parents intoclinical correspondence to ensure that they are aware<strong>of</strong>thecareplanandareinformedaboutresults<strong>of</strong>investigations. Some services already use adult role models, localself-help groups or patient volunteers as expert<strong>patients</strong>.AVPs are trained to be highly effective communicators.Relevant pr<strong>of</strong>essional interpreters must be available forboth the family and the patient during medicalconsultations, recognising that communication needsmay be different, eg a BSL interpreter for the patientand a mother-tongue interpreter for parents/carers formedical consultations.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>Both adult and paediatric AVM services are deliveredby MDTs that include other health pr<strong>of</strong>essionals,education and social services. MDTs may includecommunity paediatricians, audiologists, specialistnurses, speech and language therapists, hearingtherapists, teachers <strong>of</strong> the deaf, psychologists,behavioural therapists, educational audiologists,physiotherapists, social workers and occupationaltherapists. Each has a specific but overlapping role toplay and successful teamwork is based on mutualrecognition and respect.The patient and their family are an integral part <strong>of</strong> thisteam.Working <strong>with</strong> other specialtiesClosely linked specialties include otology, neurologyand neurosurgery, paediatrics and child health(<strong>working</strong> both in the community and in acutepaediatrics and neonatology), clinical genetics,radiology, immunology and allergy, old age medicineand ophthalmology, and many subdisciplines <strong>of</strong> generalinternal medicine. There will be a number <strong>of</strong> <strong>patients</strong>who are common to these groups, where diagnosis orcare is shared depending on the patient’s symptoms atany one time.The wide-ranging prevalence <strong>of</strong> audiovestibularsymptoms in other conditions means that AVPs willbe in contact <strong>with</strong> or receiving referrals from manydifferent disciplines.Working <strong>with</strong> GPs and GPwSIsSome GPwSIs in otolaryngology are concerned <strong>with</strong>aural care and simple audiovestibular disorders inadults and this area could be usefully expanded.Other specialty activity beyond local servicesMultiagency <strong>working</strong> is fundamental to AVM.Education services share the care <strong>of</strong> children <strong>with</strong>permanent childhood hearing impairment while socialservices and job centres are important in terms <strong>of</strong> both38 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Audiovestibular medicineTable 1 Specialised facilities required by an audiological medicine service for a population <strong>of</strong> 500,000Hearing testingPaediatric• 3 large paediatric soundpro<strong>of</strong> test booths <strong>with</strong> viewing areas• 1 standard booth <strong>with</strong> viewing area• 1 child-friendly, hearing aid fitting room• 1 room for taking impressions• 1 room for nurse-led activities, including a microscope and irrigation for aural toileting• 1 acoustically treated, child-friendly, hearing aid prescription room• 1 room for evoked-response audiometry• 1 counselling room for parents• Sufficient rooms for members <strong>of</strong> the MDT to see and work <strong>with</strong> children in a child-friendly environment, including consultationrooms for medical examination• 1 waiting room including supervised play facilities for all ages and available refreshmentsAdult• 4 standard audiometric soundpro<strong>of</strong> test booths• 1 evoked-response booth• 2 acoustically treated, hearing aid prescription rooms• 3 hearing aid fitting rooms• 2 comfortable rooms for hearing therapy• 1 room for nurse-led activities, including a microscope and irrigation for aural toileting• 1 large room for group relaxation classes• Sufficient rooms for members <strong>of</strong> the team to consult and assess <strong>patients</strong>• 1 waiting roomVestibular testingPaediatric• 1 child-friendly, purpose-designed, vestibular test room <strong>with</strong> play area and mains water supply• Facilities for comprehensive vestibular testing, including videonystagmography (VNG), electronystagmography (ENG), rotatingchair, posturography and caloric testing (needs mains water supply)• 1 clinical room for physiotherapy and occupational therapyAdult• 1 large vestibular laboratory from which light can be excluded, including VNG, ENG, rotating chair, posturography and calorictesting (needs mains water supply); it needs to be suitable for children and adults• 1 large room for group relaxation and balance retraining• 1 counselling and cognitive therapy roomOverall service• 1 seminar room for MDTs and for continuing pr<strong>of</strong>essional development (CPD)• Office space for patient administrationemployment for adults and appropriate domesticsupport for children and adults.5 Delivering a high-quality serviceWhat is a high-quality service?AVPs are medically trained pr<strong>of</strong>essionals <strong>with</strong> thehighest level <strong>of</strong> skills and competencies in the field anddeliver effective and efficient assessment, diagnosis andmanagement <strong>of</strong> disorders through an MDT in as fewvisits as possible. 12The British Association <strong>of</strong> Audiological Physicians(BAAP) policy document 2002 13 containsrecommendations for the staff and details <strong>of</strong> theequipment (less than 5 years old) required for apopulation <strong>of</strong> 500,000 <strong>patients</strong> (Tables 1 and 2). Itcovers paediatric and adult vestibular and hearingservices in both community and hospital sites. It alsorefers to the staff required for a team based at a mainunit <strong>working</strong> across several sites. BAAP published aclinical standards document in 2011 which sets out thegeneric and core standards for <strong>working</strong> <strong>with</strong> childrenC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 39


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 2 Non-medical staffing requirement for the service provided by an audiovestibular centrePr<strong>of</strong>essional Child Adult Total (500,000) Total (250,000)Audiologist Band 8B 1 1 2 2Band 7 2 1 3 2Band 6 3 3 6 3Band 5 1 3 4 2ATO 2 2 4 2SALT for hearing impaired 2 1 3 1–2Educational audiologist/ATHI 2 0 2 1Deaf role model/sign language teacher 1 0 1 0.5Social worker/counsellor 1 1 2 1Hearing therapist 0 2 2 1Physiotherapist 1 1 2 1Psychologist 1 1 2 1Paediatric occupational therapist 1 0.5 0.25 ?Nurse/healthcare assistant 1 3 4 2Medical secretary 2 2 4 2Receptionist 2 2 4 2A&Crecordsstaff 2 2 4 2ATQ = assistant technical <strong>of</strong>ficer; SALT = speech and language therapist; ATHI = advisory teacher for the hearing impaired; A&C = adultand children.and adults <strong>with</strong> hearing and balance disorders. 14Interdisciplinary standards for specific activities haveTable 3 Audiovestibular medicine guidelinesand auditsBAAP clinical standards and guidelines are available at:www.baap.org.uk/index.php?option=com content&view=article&id=48&Itemid=54NHS Newborn hearing screening protocols andpathways: http://hearing.screening.nhs.uk/publications<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians <strong>working</strong> party reportHearing and balance disorders: achieving excellence indiagnosis and management 1Department <strong>of</strong> Health documents Improving access toaudiology services in England; Transforming adulthearing services for <strong>patients</strong> <strong>with</strong> hearing difficulty;National service framework (NSF) for older people; NSFfor children, young people and maternity services; andNSF for long-term conditions. All these documents areavailable at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/index.htmbeen implemented, eg NHSP 15 and ModernisingChildren’s Hearing Aid Services (MCHAS). 16Maintaining and improving the quality <strong>of</strong> careMaintenance and improvement <strong>of</strong> service quality isensured by clinical governance, which includes: development <strong>of</strong> patient-care pathways, systems andprocesses to improve the efficiency <strong>of</strong> patient flow appraisal and peer-review system revalidation participation in accreditation <strong>of</strong> audiologydepartments, eg Improving Quality In PhysiologicalDiagnostic Services (IQIPS) adherence to published clinical standards(see Table 3) and the development <strong>of</strong> national andlocal guidelines reviewed by audit participation <strong>of</strong> AVPs in BAAP specialty-specificnational audit participation <strong>of</strong> AVPs in regional and national work,eg for BAAP and in partnership <strong>with</strong> otherpr<strong>of</strong>essional and voluntary bodies such as the British40 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Audiovestibular medicineAcademy <strong>of</strong> Audiology (BAA), the Department <strong>of</strong>Health (DH), the <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP)and NDCS encouragement by BAAP through appointment <strong>of</strong> asecond AVP where possible in areas where there is asingle-handed AVP education and training ensuring publication <strong>of</strong>cross-discipline information, conferences, teachingand learning opportunities, both locally andinternationally, especially through the InternationalAssociation <strong>of</strong> Physicians in Audiology (IAPA),which publishes Hearing Balance andCommunication research in conjunction <strong>with</strong> healthcarepr<strong>of</strong>essionals, basic scientists and <strong>patients</strong> into thepathophysiology and management <strong>of</strong>audiovestibular disorders.Specialty and national guidelinesTable 3 gives details <strong>of</strong> AVM guidelines and audits.6 Clinical work <strong>of</strong> consultantsOutside academic units, all AVPs work exclusively intheir specialty, almost entirely <strong>with</strong> out<strong>patients</strong>. In unitswhere there are no trainees, work is direct rather thansupervisory but is always as part <strong>of</strong> an MDT.Inpatient workAVPs do not have dedicated inpatient beds, but in anaverage DGH approximately four in<strong>patients</strong> per weekare likely to be referred from other specialties fordiagnostic consultation.Outpatient workA consultant AVP <strong>working</strong> alone in an adult outpatientclinic may see 4–6 new <strong>patients</strong> or 8–12 follow-up<strong>patients</strong> per programmed activity (PA). In a paediatricoutpatient clinic, a maximum <strong>of</strong> six new or follow-up<strong>patients</strong> may be seen. The number will depend on theconsultant’s experience, the complexity <strong>of</strong> the problemsand the availability <strong>of</strong> support staff. In some highlyspecialist services fewer <strong>patients</strong> may be seen.When supervising trainees, the numbers <strong>of</strong> <strong>patients</strong> inclinics should be adjusted to allow for teaching anddiscussion <strong>of</strong> cases.Specialist activities beyond thelocal servicesSome clinical work can be undertaken by telephoneconsultation and email.Specialist investigative and therapeuticproceduresWhenever possible, audiovestibular investigationsshould be carried out at the same attendance as theclinic appointment; this might be combined <strong>with</strong>assessment and advice from other pr<strong>of</strong>essionals <strong>with</strong>inthe MDT. However, this makes the timing <strong>of</strong> clinicsunpredictable as some <strong>patients</strong> will inevitably takelonger to assess than others, especially the very youngor the very old.Most investigative and therapeutic procedures arecarried out by other pr<strong>of</strong>essionals but the coordinationand interpretation is <strong>of</strong>ten by AVPs.Specialist on callThere is no on-call requirement for AVM nor doconsultants and trainees participate in the on-call rotafor acute general internal medicine. They may, however,be closely involved in the management <strong>of</strong> two acutepresentations: sudden hearing loss and acute intractablevertigo. Both conditions require urgent admission,investigation and management in collaboration <strong>with</strong>otology and/or neurology.Other specialist activityMany AVPs undertake clinical work and teaching inmore than one site, including outreach clinics in DGHs,community clinics, primary-care groups, schools for thedeaf or learning disabled, and domiciliary visits toprivate homes or residential accommodations.An AVP’s work encompasses duties in clinicalgovernance, pr<strong>of</strong>essional self-regulation, CPD, andeducation and training <strong>of</strong> others. For many consultantsat various times in their careers it may include research,serving in management, and providing specialist adviceat local, regional and national levels. In a small specialty,work for the RCP, government, specialist societies,patient groups, deaneries and other national bodies is agreater burden than in larger specialties where themajority <strong>of</strong> consultants may not be involved if they arenot so inclined.Clinically related administrationThe specialist nature <strong>of</strong> the work, lack <strong>of</strong> generalknowledge about audiovestibular disorders, tertiary,interdisciplinary and multiagency <strong>working</strong>, and thepersonal approach to management inherent in the field,result in the generation <strong>of</strong> a considerablecommunication burden for AVPs and A&C staff.Preparation <strong>of</strong> complex reports may take half as long asC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 41


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>thetimetoseethepatient.Therearenumbers<strong>of</strong>requests for clinical information from patient agencies,<strong>patients</strong>, other pr<strong>of</strong>essionals and specialists, and forinformation and documentation to supportentitlements such as the disability living allowance,statements <strong>of</strong> special educational needs, rehousing andimmigration. Adequate administrative infrastructurefor secretarial support, appointments and medicalrecords is essential.7 Opportunities for integrated careAudiovestibular <strong>physicians</strong> can provide integrated care<strong>with</strong> the following services: falls clinics adult and paediatric neurology services adult and paediatric otology services community-commissioned audiological andvestibular services genetics dual visual and hearing loss clinics educational audiology social work for deaf people speech and language therapy.8 Workforce requirements for the specialtyA population <strong>of</strong> 250,000 generates approximately 1,000new AVM referrals per year and 1,000 follow-upappointments. The follow-up rate is kept low, despitethe specialty being largely concerned <strong>with</strong> chronicdisease, because non-medical members <strong>of</strong> the MDTundertake much <strong>of</strong> the rehabilitation work.Current workforce numbersThere are currently 49 consultant AVPs in England, onein Wales and one in Scotland; giving a total <strong>of</strong> 51. Most<strong>of</strong> these work full time. There are also 12 consultantcommunity paediatricians in audiology, 19 StRs(specialty registrars) – 7 flexible. There are nonon-consultant career grade doctors or GPwSIs.Providing an audiovestibular medicine serviceto a population <strong>of</strong> 250,000The specialist society 13 recommends that onewhole-time equivalent (WTE) adult and one WTEpaediatric AVP would be needed to provide this service.This assumes that there are sufficient numbers <strong>of</strong>pr<strong>of</strong>essionals in the MDT.National consultant workforce requirementsAn initial increase <strong>of</strong> 104% across the UK is thought tobe an appropriate target over the next few years, <strong>with</strong> anaim <strong>of</strong> achieving one WTE per 300,000 population. 1The aim must be to provide the best service for <strong>patients</strong>using an appropriate balance <strong>of</strong> AVPs, communitypaediatricians and audiologists <strong>working</strong> closely <strong>with</strong>their ENT colleagues.Calculating the numbers for academic staff is morechallenging: the MSc and diploma courses are largelydependent on the teaching <strong>of</strong> honorary staff, despiteattracting a large number <strong>of</strong> overseas, as well as local,students. The success <strong>of</strong> integrated scientific andclinical research supports the demand for an increase inthis faculty.9 <strong>Consultant</strong> work programme/specimenjob planTables 4 and 5 give examples <strong>of</strong> job plans for consultantsplaced in either paediatric or adult work. For those whocover both areas, a hybrid plan would be neededaccording to the service demands <strong>of</strong> the department.Please note that, because this is a complex rehabilitativefield, the paperwork can be heavy and needs to beadequately catered for in any job plan; the ratio <strong>of</strong>administration:face-to-face patient contact can be0.5:1 to 1:1.10 Key points for commissioners1 Audiovestibular <strong>physicians</strong> (AVPs) are well placedto advise on planning and commissioning specialistservices because <strong>of</strong> their training andmultidisciplinary work. Their pr<strong>of</strong>essionalstandards and national collaborations wouldensure that significant national variation <strong>of</strong> hearingand balance service provision is minimised, whilemaintaining a focus on local needs.2 Commissioning <strong>of</strong> audiovestibular medicine(AVM)servicesonaregionalbasiswouldensurethat the specialist skills <strong>of</strong> the limited number <strong>of</strong>AVPs are used most effectively. This would enabledevelopment <strong>of</strong> robust regional networks forhearing and balance services which would belocated <strong>with</strong>in tertiary centres.3 A nationwide, integrated AVM service shouldinclude cooperative work <strong>with</strong> colleagues <strong>with</strong>complementary competences and <strong>with</strong> GPs,42 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Audiovestibular medicineTable 4 <strong>Consultant</strong> in paediatric audiovestibular medicineActivity Workload Programmed activities (PAs)Outpatient workGeneral hearing clinics A maximum <strong>of</strong> 6 <strong>patients</strong> –commonly a ratio <strong>of</strong> 1 newpatient to 2 follow-up3–5Specialist clinics Vestibular 2–3 <strong>patients</strong> new or follow-up Depending on subspecialisationand demand 1–2Speech and languageCochlear implantNHSP2–3 <strong>patients</strong> new or follow-up2–3 <strong>patients</strong> new or follow-up2newor4follow-upWork outside hospital base Special schools 0–1Multidisciplinary work 1Direct patient careMinimum <strong>of</strong> 0.5 PA admin: 1 PAclinic2.5–3On call for specialist advice andemergenciesDepends on centre 0–0.5Acute medicine rota Rare 0Total direct patient care PAs 7.5Supporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improvethe quality <strong>of</strong> healthcareEducation and training,appraisal, departmentalmanagement and servicedevelopment, audit and clinicalgovernance, CPD andrevalidation, research2.5Total PAs 10Additional PAsOther NHS responsibilitiesExternal dutieseg medical director, clinicaldirector, lead consultant inspecialty, clinical tutoreg work for deaneries, royalcolleges, specialist societies, DHor other government bodiesNegotiableNegotiablethrough formally embedded pathways. This serviceshould be designed utilising the clinical networkexpertise from other services <strong>with</strong> a proven trackrecord (eg cancer services).4 AVPs should work <strong>with</strong> local GPs to promote‘self-care’ <strong>of</strong> AV problems and address inequalities<strong>with</strong>in disadvantaged and minority groups.5 As multidisciplinary secondary-care <strong>physicians</strong><strong>with</strong> additional training in paediatrics, AVPs have awide knowledge <strong>of</strong> hospital and non-hospital care,and are well placed to sit on boards <strong>of</strong> clinicalcommissioning groups and other nationalgovernment and non-government bodies.6 AVM should be easily locatable in the Choose andBook service, <strong>with</strong> a named consultant to facilitatepatient choice and easy access to treatment <strong>of</strong>complicated problems. This would optimisereferral patterns and quality <strong>of</strong> care.7 Health and wellbeing boards should considerformally supporting local adult and children’shearing and balance services <strong>working</strong> groups, inorder to facilitate the patient’s voice and jointC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 43


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 5 <strong>Consultant</strong> in adult audiovestibular medicineActivity Workload Programmed activities (PAs)Outpatient workGeneral hearing clinics 4–6 new <strong>patients</strong> or 3–58–12 follow-up <strong>patients</strong> orcombinationSpecialist clinics Vestibular triage clinic 10 new <strong>patients</strong> 1–2Specialist diagnostic/management clinicSupra-specialist clinicAdult tinnitusCochlear implantAdult learning disabled3–4 new <strong>patients</strong> and4–5 follow-up4 new <strong>patients</strong>4–6 <strong>patients</strong> new or follow-up2–3 <strong>patients</strong> new or follow-up2–4 <strong>patients</strong> new or follow-upMultidisciplinary work 1Clinically related administration 2.5–3On call for specialist advice and emergencies Depends on centre 0–0.5Acute medicine rota Rare 0Total direct patient care PAs 7.5Supporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improvethe quality <strong>of</strong> healthcareEducation and training, appraisal,departmental management andservice development, audit andclinical governance, CPD andrevalidation, research2.5Total PAs 10Additional PAsOther NHS responsibilitiesExternal dutieseg medical director, clinicaldirector, lead consultant inspecialty, clinical tutoreg work for deaneries, royalcolleges, specialist societies, DH orother government bodiesNegotiableNegotiable<strong>working</strong> between AVM services and voluntarybodies (eg NDCS, AFD), education, localsensory support, social services and publichealth.8 AVM services should participate in and supportnational audits against published clinical standards.9 The establishment <strong>of</strong> national registers for outcomecomparison is required, to ensure quality andconsistency <strong>of</strong> care, regardless <strong>of</strong> who is providingAVM services.10 To ensure equality in healthcare provision, and forthe wider health and economic benefit to thepatient’s quality <strong>of</strong> life, AVPs should be appointedin those large areas <strong>of</strong> the country where AVM islacking, or when an AVP or paediatrician <strong>with</strong> aspecial interest in audiovestibular medicine is dueto retire. This would ensure that the holisticapproach <strong>of</strong> AVM is maintained and that there iscontinuous improvement in standards <strong>of</strong> care thatcan be applied across the country.Relevant publications Department <strong>of</strong> Health. Equity and excellence:liberating the NHS. London: DH, 2010. 1744 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Audiovestibular medicine <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. The RCP response toLiberating the NHS: commissioning for <strong>patients</strong>. 18 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Hearing and balancedisorders: achieving excellence in diagnosis andmanagement. Report <strong>of</strong> a <strong>working</strong> party. London:RCP, 2007. 1References1 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Hearing and balancedisorders: achieving excellence in diagnosis andmanagement. Report <strong>of</strong> a <strong>working</strong> party. London: RCP,2007.2 Yardley L, Owen N, Nazareth I, Luxon L. Prevalence andpresentation <strong>of</strong> dizziness in a general practice communitysample <strong>of</strong> <strong>working</strong> age people. Br J Gen Pract1988;48:1131–5.3 <strong>Royal</strong> National Institute for the Deaf. www.rnid.org.uk/information resources/aboutdeafness/statistics/4 Niemensivu R, Pyykko I, Wiener-Vacher SR, Kentala E.Vertigo and balance problems in children – anepidemiologic study in Finland. Int J PediatrOtorhinolaryngol 2006;70:259–65.5 National Deaf Children’s Society. http://rm3-ndcs.torchboxapps.com/for the media/faqs 1.html#faqblock46 Fortnum HM, Summerfield AQ, Marshall DH, Davis ACBamford JM. Prevalence <strong>of</strong> permanent childhood hearingimpairment in the United Kingdom and implications foruniversal neonatal hearing screening: questionnairebased ascertainment study. BMJ 2001;323:536–40.7 Department <strong>of</strong> Health. Health survey for England 1997.London: DH, 1997.8 HaggardM,HughesE.Screening children’s hearing: areview<strong>of</strong>theliteratureandtheimplications<strong>of</strong>otitismedia.London: DH, 1997.9 National Institute for Health and Care Excellence.Surgical management <strong>of</strong> otitis media <strong>with</strong> effusion inchildren. Clinical guideline CG60. London: NICE,2008.10 MRC Institute <strong>of</strong> Hearing Research, APD Special InterestGroup, 2004. www.ihr.mrc.ac.uk11 Turner-Boutle M. On the evidence. Pre-school hearing,speech, language and vision screening. Health Serv J1998;108:36–7.12 Health and Social Care Information Centre. The 18 weeksdelivery programme, audiology pathway.www.ic.nhs.uk/webfiles/Events/SUS%20AWARENESS%20EVENTS/HEATHER%20CORLETT.pdf13 British Association <strong>of</strong> Audiological Physicians. Auditory,balance and communication disorders. Audiologicalmedicine in the UK: a guide for users, commissioners andproviders. Policy document. London: BAAP, 2002.www.baap.org.uk/images/stories/BAAP Policy Doc.pdf14 British Association <strong>of</strong> Audiovestibular Physicians.Clinical standards – setting standards to improvecare for <strong>patients</strong> <strong>with</strong> hearing and balance disorders. UK:BAAP, 2011.http://baap.org.uk/images/stories/baapcs.pdf15 Newborn Hearing Screening Programme. Guidelines forthe aetiological investigation <strong>of</strong> infants.http://hearing.screening.nhs.uk/medical#fileid1648416 University <strong>of</strong> Manchester. Modernising children’shearing aid services.www.psych-sci.manchester.ac.uk/mchas/17 Department <strong>of</strong> Health. Equity and excellence: liberatingthe NHS. London: DH, 2010.18 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. The RCP response toLiberating the NHS: commissioning for <strong>patients</strong>.www.rcplondon.ac.uk/policy/responding-nhsreform/liberating-nhsC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 45


2 Specialties Cardiovascular medicineCardiovascular medicine and paediatric cardiology<strong>with</strong> adult congenital cardiologyDr Jane Flint BSc MD FRCP <strong>Consultant</strong> cardiologist1 Description <strong>of</strong> the specialtyWhat is the specialty?Cardiovascular medicine involves the management <strong>of</strong><strong>patients</strong> <strong>with</strong> suspected or confirmed cardiovasculardisease and conditions <strong>of</strong> the heart, circulation andlinked organs associated <strong>with</strong> diabetes, renal disease orcerebrovascular disease. Paediatric cardiology is aspecialty that deals <strong>with</strong> all aspects <strong>of</strong> care <strong>of</strong> <strong>patients</strong><strong>with</strong> congenital heart disease, from before birth toadulthood. More and more <strong>patients</strong> have grown-upcongenital heart disease (GUCH) and they are followedin GUCH centres and local centres <strong>with</strong> joint expertise –an example <strong>of</strong> improved integration <strong>of</strong> services (seesection 7). Regionally coordinated genetics andpathology services are being developed forinvestigation <strong>of</strong> people <strong>with</strong> a family history <strong>of</strong> suddendeath. There is no room for complacency if we are toprevent further cases <strong>of</strong> premature cardiac death andimprove quality <strong>of</strong> life for people <strong>with</strong> chronic heartdisease.Who are the <strong>patients</strong>?Most <strong>patients</strong> arrive at emergency departments as acuteadmissions, presenting <strong>with</strong> shortness <strong>of</strong> breath, chestpain or some other cardiac symptom such as transientloss <strong>of</strong> consciousness. They are stratified according torisk so that those <strong>with</strong> acute coronary or anotherhigh-risk syndrome (eg arrhythmia) receive appropriatespecialist care on cardiac care units (CCUs), or oncontinuing care or heart failure wards. By mid 2011,94% <strong>of</strong> <strong>patients</strong> <strong>with</strong> ST-elevation myocardial infarction(STEMI) were taken to network-designated centres inEngland for primary percutaneous coronaryintervention (PPCI). 1 Follow-up <strong>of</strong> many differentcardiac disorders <strong>with</strong> increasing subspecialty focus,eg cardiomyopathy and valve disease, isappropriate. Congenital heart disease affects 8out <strong>of</strong> every 1,000 live births, and this represents amajor clinical challenge for detection andmanagement.Main disease patternsThe current emphasis is on early primary prevention,diagnosis and secondary prevention in a largerpopulation <strong>of</strong> people <strong>with</strong> coronary heart disease whoare living for longer. The increase in <strong>patients</strong> <strong>with</strong>heart failure is being addressed through specialisedsupport in the community, but palliative care for<strong>patients</strong> <strong>with</strong> heart failure and cardiac rehabilitationcompleting all care pathways are priorities inEngland in the cardiovascular disease (CVD)Outcomes Strategy (March 2013). Severe aorticstenosis in frail <strong>patients</strong> can now be managed bytransarterial valve implantation (TAVI). The field <strong>of</strong>paediatric cardiology has also become increasinglysubspecialised, <strong>with</strong> new developments in prenataldetection and interventional and electrophysiologicaltreatments, and the outlook for these <strong>patients</strong> hasbeen greatly improved. Treatments for pulmonaryhypertension, cardiac transplantation, andimplantation <strong>of</strong> left ventricular assist devices (LVADs)are concentrated <strong>with</strong>in supra-regional centres. Thepattern <strong>of</strong> endocarditis is ever-changing, and extravigilance is needed since the National Institute forHealth and Care Excellence (NICE) recommendedremoving routine prophylaxis for most susceptible<strong>patients</strong> in 2008.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceThe aim is to provide a seamless transition for adult andchild <strong>patients</strong> from primary to secondary and then totertiary care, as necessary, and back to localrehabilitation <strong>with</strong>in cardiac networks through the use<strong>of</strong> agreed care pathways. Some advances in serviceprovision pioneered <strong>with</strong>in tertiary care are appropriatefor regular use in secondary care, such as implantationprocedures and follow-up <strong>of</strong> <strong>patients</strong> <strong>with</strong> implantablecardioverter defibrillators (ICDs). A key part <strong>of</strong> theagenda for cardiac networks is equity <strong>of</strong> healthcareC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 47


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>across sectors. It is hoped that the outcome forpaediatric cardiology <strong>with</strong>in the review Safe andsustainable children’s congenital heart services 2 willsupport continued access to similarly integratedprimary, secondary and tertiary care for all regions.Supra-regional services should be justifiablyrationalised to preserve quality for <strong>patients</strong>(and their families) who have to travel somedistance.Primary care is focused on primary prevention andlifestyle counselling, through monitoring andmanagement <strong>of</strong> hypertension, hyperlipidaemia,diabetes and renal disease. It also involves secondaryprevention <strong>of</strong> chronic coronary heart disease andmonitoring <strong>of</strong> heart failure. The main emphasis inpaediatric cardiology should be on the earlydetection and prevention <strong>of</strong> congenital heart disease.Symptoms must be recognised, and innocent heartmurmurs must be differentiated from pathologicalones.Paediatricians in secondary care <strong>of</strong>fer reassurance to<strong>patients</strong> <strong>with</strong> innocent murmurs, and those who have aspecial interest in cardiology are greatly valued.Secondary care can provide almost all acute cardiac careandelectiveoutpatientinvestigationsinadults,<strong>with</strong>interventions other than implantation <strong>of</strong> pacemakersand complex devices being through network agreement(see Table 1).Tertiary care provides surgery for disease <strong>of</strong> thecoronary arteries, aorta and valves, as well as complexinterventions <strong>with</strong> on-site surgical cover, paediatricand GUCH centres (see above), interventions <strong>with</strong>advanced imaging support, and complex invasiveelectrophysiology. ‘Heart-attack centres’ for <strong>patients</strong>who need PPCI tend to be based (but not exclusively)in tertiary care.Sources <strong>of</strong> referral from primary, secondary andtertiary levelsIn addition to the above, one-stop clinics are indevelopment, following the success <strong>of</strong> rapid access for<strong>patients</strong> <strong>with</strong> angina. These clinics are for <strong>patients</strong> <strong>with</strong>heart failure and arrhythmias, and have protocols forthe management <strong>of</strong> atrial fibrillation through fromprimary care. Strong secondary care is vital for thesupervision <strong>of</strong> care pathways and community clinics.Risk assessment in secondary care to determine theneed for catheterisation and onward referral forintervention or surgery is critical for all <strong>patients</strong> <strong>with</strong>cardiac conditions. Tertiary care should <strong>of</strong>fer amultidisciplinary approach for assessing the optimumintervention in referred <strong>patients</strong>. Patients should berepatriated locally for rehabilitation and follow-up afteran intervention at the tertiary level, and this should beensured in care pathways. Special patterns <strong>of</strong> referral for<strong>patients</strong> <strong>with</strong> congenital heart disease may occur, butthe local secondary care service should maintaindocumentation in these cases. Prenatal detectionservices are not comprehensively available, and babieswho are suspected <strong>of</strong> having congenital heart disease arereferred from secondary care to outreach clinics,tertiary centre clinics, or as in<strong>patients</strong>, depending upontheir clinical condition. Children who need cardiacsurgery are referred by paediatric cardiologists, ratherthan directly to cardiac surgeons by either their GP or alocal paediatrician. A breathless baby <strong>with</strong> cyanosisshould be referred urgently to a tertiary carespecialist.Locality-based and regional servicesPatient and carer stakeholder discussions <strong>with</strong>in thenetworks have expressed a wish for local districtservices, except where network or regional levels confersome additional benefit, as described above (see alsosection 1). The cardiovascular network strategy and thecoordination <strong>of</strong> jointly agreed standards for specialisedservices across several networks can determine thelocation <strong>of</strong> newer strategic services for the <strong>patients</strong>described in section 1. This model is ideal forinvolvement <strong>of</strong> commissioners (see section 10). Thefamilies <strong>of</strong> children <strong>with</strong> congenital heart disease arecontent to travel greater distances in order to benefitfrom definitive, specialised surgery in an appropriatelycommitted environment.Community models <strong>of</strong> careThere are registers in primary care for people at risk <strong>of</strong>cardiovascular disease (including smokers, obese anddiabetic <strong>patients</strong>) and <strong>patients</strong> <strong>with</strong> coronary heartdisease or heart failure. This was recommended inEngland by the national service framework (NSF) forcoronary heart disease. 3 Pr<strong>of</strong>essional communityhealthcare networks are increasing for <strong>patients</strong> <strong>with</strong>heart failure and for people in need <strong>of</strong> palliative care orrehabilitation. Non-invasive cardiac investigations maybe practised, ideally under the supervision <strong>of</strong> specialists,in line <strong>with</strong> care pathways linked to local cardiologyservices. Cardiac rehabilitation, particularly during themaintenance phase, may be community based.48 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Cardiovascular medicineTable 1 Service location and main activitiesService locationPrimary cardiaccareCommunitycardiologySecondarycardiac careTertiary cardiaccareMain activitiesPrimary and secondary preventionMonitoring and management <strong>of</strong>:hypertension (eg ambulatory blood pressure)hyperlipidaemiadiabetesrenal conditions.Resting ECG testsMonitoring and management <strong>of</strong> stable chronic diseases, eg coronary heart disease, heart failureSome investigation and management <strong>of</strong> heart failure (community echo and blood tests)Ambulatory monitoring <strong>of</strong> blood pressure and ECGCardiac rehabilitationEmergency care <strong>of</strong>:acute chest paincollapseacute breathlessness suspected to be cardiac in originacute coronary conditions (heart attack)acute arrhythmiasacute heart failureheart infections (endocarditis)diseases <strong>of</strong> the heart muscleacute pericardial conditions.Clinical management <strong>of</strong> cardiac care unitsIn<strong>patients</strong> <strong>with</strong> cardiac conditionsCardiac day cases for investigation or treatmentInvestigation <strong>of</strong> suspected cardiac symptoms – in rapid-access chest pain clinics, and newer one-stop clinics forheart failure, arrhythmiasFollow-up <strong>of</strong> <strong>patients</strong> <strong>with</strong> certain valve disorders, cardiomyopathies, pericardial conditions and arrhythmiasFollow-up <strong>of</strong> some <strong>patients</strong> <strong>with</strong> congenital heart diseaseGeneral outpatient clinicsEchocardiography studies, transthoracic, transoesophageal and stress exercise ECG investigationsNuclear cardiology studies, some CT and MRIAmbulatory analyses <strong>of</strong> ECG and blood pressureInvestigations <strong>of</strong> autonomic function, eg tilt-table testingDiagnostic cardiac catheterisation and angiographySome percutaneous coronary intervention (PCI)Implantation <strong>of</strong> temporary pacemakersImplantation, renewal and follow-up <strong>of</strong> permanent pacemakers including complex devices, eg CRTSome electrophysiological studies and routine ablationImplantable ECG loop recordersImplantation and renewal <strong>of</strong> intracardiac/subcutaneous defibrillatorsCardiac rehabilitationAll secondary care services for their local population, plus:Emergency PPCI for STEMIComplex interventions:percutaneous closure <strong>of</strong> PFOpercutaneous closure <strong>of</strong> ASDsnon-surgical reduction <strong>of</strong> myocardial septumpercutaneous laser revascularisation for refractory anginacarotid artery stent placement for carotid stenosispercutaneous occlusion <strong>of</strong> left atrial appendagepercutaneous mitral valvuloplastypercutaneous aortic valvuloplasty and aortic valve replacementpercutaneous closure <strong>of</strong> acquired VSD.(continued)C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 49


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Service location and main activities (continued)Service locationMain activitiesManagement <strong>of</strong> rare cardiac arrhythmias (eg congenital long QT syndrome, Brugada’s syndrome,arrhythmogenic right ventricular dysplasia, ventricular arrhythmias associated <strong>with</strong> familialcardiomyopathies)Screening families affected by sudden cardiac deathManagement <strong>of</strong> some cardiomyopathiesExtraction <strong>of</strong> pacemaker leads <strong>with</strong> special equipmentCardiac surgeryComplex cardiac interventionsAdvanced cardiac electrophysiologySupra-regionalcardiologyPaediatric cardiologyAssessment <strong>of</strong> adults <strong>with</strong> congenital heart diseaseMost interventions in adults <strong>with</strong> congenital heart diseaseFollow-up <strong>of</strong> certain adults <strong>with</strong> congenital heart diseasePulmonary hypertensionImplantation <strong>of</strong> left ventricular assist devicesCardiac transplantationCardiopulmonary transplantationECG = electrocardiography; PFO = patent foramen ovale; ASD = atrioseptal defect; VSD = ventriculoseptal defect; STEMI = ST-elevation myocardialinfarction.Community cardiology is an expanding subspecialtythat has a particular interest in these areas.Complementary servicesComplementary therapies do not play a major role inthe management <strong>of</strong> heart disease. However, some<strong>patients</strong> have access to various therapies through linksbetween voluntary services and patient and carergroups.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcarePatient and carer involvement in cardiac servicesIn 2003, the British Cardiovascular Society (BCS)established a broad-based group to represent theinterests and aspirations <strong>of</strong> cardiac <strong>patients</strong> and theircarers. The Cardiovascular Care Partnership UK (CCPUK) was developed as an affiliated group <strong>of</strong> BCS in 2004to act as the patient arm <strong>of</strong> cardiology. Trustees aredrawn from various cardiac patient and carer charities,including the Children’s Heart Federation (CHF), theGUCH Association, the British Heart Foundation(BHF) Heart Support Group network, thecardiovascular network patient and carer partnerships<strong>of</strong> England, and various healthcare pr<strong>of</strong>essionalscommitted to patient empowerment.The CCP UK is represented on the patient involvementpanel <strong>of</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP), the JointSpecialty Committee for Cardiology, the board <strong>of</strong>Myocardial Infarction Audit Project (MINAP), Societyfor Cardiothoracic Surgery (SCTS), Department <strong>of</strong>Health’s (DH) <strong>working</strong> groups on cardiovascularmedicine and stroke, BHF, National Audit <strong>of</strong> CardiacRehabilitation (NACR), NICE consultations, NSFchapter groups for GUCH and arrhythmias, and theNHS Improvement Heart team.Patient-centred care in integrated care pathwaysA formal description <strong>of</strong> a patient’s view <strong>of</strong> the essentialelements <strong>of</strong> the care pathway is given in the Fifth reporton the provision <strong>of</strong> services for <strong>patients</strong> <strong>with</strong> heartdisease. 4 Among the issues raised were: involvement in decisions regarding treatment receipt <strong>of</strong> appropriate information time to interpret and reflect before decisions aremade partnership <strong>with</strong> pr<strong>of</strong>essionals in their care support <strong>of</strong>fered earlier in care pathways promotion <strong>of</strong> cardiac rehabilitation and supportgroups.Patients help to define care pathways through theirinvolvement <strong>with</strong> quality in practice teams <strong>working</strong> in50 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Cardiovascular medicineall healthcare trusts under proper governance, and incardiovascular networks. Both <strong>patients</strong> and carersdemand that healthcare pr<strong>of</strong>essionals consider theirgender, age, ethnic background and religious choices,and should seek advice for unfamiliar problems.Assessment <strong>of</strong> the impact <strong>of</strong> diversity on care pathwaysis exemplified by patient involvement in the BCS JointWorking Group recommendations for women’s hearthealth. Patient support groups are recommendedbecause they <strong>of</strong>fer sensible companionship, advice,activities and support.Promoting self-care through educationIt is essential to give appropriate information (such asthat provided by the BHF) to <strong>patients</strong> early in the acutecare pathway, and <strong>patients</strong> should have ready access t<strong>of</strong>urther advice (see below). Self-care is encouraged,particularly for <strong>patients</strong> moving up from anappropriate local cardiac rehabilitation programme,when the time is right for further training in order forthem to become expert <strong>patients</strong>, capable <strong>of</strong> fullyunderstanding and managing their situation, andaccepting challenges so that their life is as tolerable andfulfilled as possible. They can also guide others. Patientscan be further empowered by BHF’s Hearty voices, theConsumer Council’s Stronger voices, and the trainingprogrammes provided by CCP UK and new NHSstructures. Participation in multidisciplinary teams(MDTs) <strong>with</strong> staff (see section 4) may also improve thepatient experience. Their involvement in supportgroups will help other <strong>patients</strong>, as will <strong>working</strong> oncommittees and groups for service users including thenew commissioning structures (see section 10).The role <strong>of</strong> the carerThe vital link between the patient and the carer isrespected by cardiac network patient and carerpartnerships, and by support groups <strong>of</strong> the CCP UK.The carers should understand their role as the thirdcorner in the dynamic triangle <strong>with</strong> the patient and theclinician, and they should be aware <strong>of</strong> the risks <strong>of</strong> thepatient’s heart disease and any interventions. Theactivities <strong>of</strong> the CHF charities since the Bristol Enquiryare good examples <strong>of</strong> parent and carer empowerment interms <strong>of</strong> influencing service reviews.Communication <strong>with</strong> <strong>patients</strong>Information and communication are high priorities.Access to information should be provided at all thedefined stages <strong>of</strong> an integrated care pathway (eg recentNHS Improvement recommendations for post-PPCIinformation and cardiac rehabilitation). Informationshould be provided in an easy to understand format andshould include websites and contact details for localclinical advisers and patient experts. Newsletters fromdisease-specific support groups are also helpful (such asthe Sudden Arrhythmic Death Syndrome support groupand the Cardiomyopathy Association). Full patientdocumentation (eg copies <strong>of</strong> letters and test results) isuseful for the patient’s personal health record, as well ashospital and primary care records. In paediatriccardiology, letters are routinely copied to <strong>patients</strong> andcarers. The CCP UK emphasises that consultants shouldstrive to help every patient reach a level <strong>of</strong>understanding comparable to that <strong>of</strong> an expert patient.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>Multidisciplinary <strong>working</strong> is well established incardiology practice, <strong>with</strong> acute involvement <strong>of</strong> cardiacnurses, cardiac physiologists and radiographers.Surgeons, anaesthetists, intensivists and cardiacsubspecialties such as interventionalists, pharmacistsand play specialists for children may also be needed.The full cardiac rehabilitation team also benefits frompr<strong>of</strong>essional expertise in exercise, as well as educationalinput from dietitians, smoking cessation counsellors,clinical psychologists and stress managers. Stronggroups affiliated to the BCS set standards inmultidisciplinary <strong>working</strong> in many areas, such asechocardiography, nuclear cardiology, intervention,rehabilitation and heart failure, and they have informedBCS’s peer-review process. Clinical governancedemands multidisciplinary <strong>working</strong>, and many trustshave set up teams to develop quality in practice. TheNSF for coronary heart disease enforced localmultidisciplinary implementation teams, whichreflected the whole integrated care pathway, and cardiacnetworks which involved Service Improvement staff.Working <strong>with</strong> other specialtiesCardiologists in larger district general hospitals(DGHs) concentrate on <strong>patients</strong> <strong>with</strong> cardiovasculardisease <strong>with</strong>in the acute medical ‘take’ and <strong>of</strong>ten workin acute medical units to assess <strong>patients</strong>’ risks. They maycontribute outreach teams to emergency departments. Acontinuing, close and effective <strong>working</strong> relationship <strong>with</strong>front-door teams is essential. Patients admitted as emergencies<strong>with</strong> important cardiac diseases should rightlyexpect to be seen by a cardiologist <strong>with</strong>in 24 hours, 4 and24/7 services are rapidly evolving for the cardiac intake.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 51


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>In tertiary centres, the multidisciplinary forum, whichincludes cardiac surgeons and cardiac interventionalists(for both adults and children), is a vital quality standardfor assessing the appropriate treatments for all <strong>patients</strong>,including children. The interface between radiologyand cardiology in terms <strong>of</strong> expertise in imagingand its place <strong>with</strong>in the MDT in the future is an areafor development. The way it evolves will largely dependon local interest and expertise. There is improvingcooperation among the BCS-affiliated groups forimaging modalities. The increasing focus on vascularmedicine is facilitating closer <strong>working</strong> relationshipsbetween specialists in vascular surgery, nephrologyand diabetes, particularly <strong>with</strong> respect to preoperativeassessment, and these will also extend from the CVDOutcomes Strategy 2013. The treatment <strong>of</strong> <strong>patients</strong><strong>with</strong> infective endocarditis involves cooperation<strong>of</strong> specialists in microbiology and cardiac surgery <strong>with</strong>those in cardiology. There are increasing numbers <strong>of</strong>joint GUCH clinics, which allow specialists to visit localcentres.Working <strong>with</strong> GPs and GPs <strong>with</strong> a special interest(GPwSIs)Some GPs are especially interested in cardiovascularmedicine, and GPwSIs have been developed <strong>with</strong> inputfrom the RCP, the BCS and NHS Improvement foraccreditation. Clinical assistants and hospitalpractitioners should receive this further training toallow them to contribute to services that they typicallyprovide in outpatient or non-invasive investigativecardiology settings. They have a useful role in localmanagement boards and networks for vascular andchronic diseases, and they may become leads, forexample, in developing community cardiac clinics forhypertension and palpitations. The Primary CareCardiovascular Society is an important affiliated group<strong>of</strong> the BCS.Other specialty activity beyond local servicesSpecialised commissioning activity <strong>of</strong>ten relates to agroup <strong>of</strong> networks for which standards must be agreedto allow development, and the BCS can contribute thestrength <strong>of</strong> its affiliated groups and committees.Regional and national reviews <strong>of</strong> services have beeninfluenced, for example, by the workforce requirementsidentified by the BCS (see section 8). Closercooperation <strong>with</strong> other organisations is a formalstrategy, as exemplified by the Cardio & VascularCoalition through the production <strong>of</strong> Destination 2020and Access to cardiac care in the UK. 5,6 Hopefully thiswill be noted in new commissioning structures (seesection 10). A specific resource pack on commissioning<strong>of</strong> cardiac services has been produced by the BCS. 75 Delivering a high-quality serviceCharacteristics <strong>of</strong> a high-quality serviceA national cardiac conference was held in March 2010(see Box 1) to celebrate the achievements over 10 yearsfollowing the publication <strong>of</strong> NSF for coronary heartdisease in England, which enumerated 12 standards <strong>of</strong>care. These were further elaborated on over that 10-yearperiod by Chapter eight: arrhythmias and sudden cardiacdeath, 8 a GUCH guide, and multiple guidelines fromNICE (see Table 2).Success has been seen <strong>with</strong> rapid-access chest painclinics for angina and the prompt referral <strong>of</strong> <strong>patients</strong><strong>with</strong> acute coronary syndrome to cardiologists forangiography, percutaneous coronary intervention orcoronary artery bypass grafting. There has also been amajor reduction in waiting times for investigations andtreatment.However, there is still room for improvement in manyareas, such as cardiac rehabilitation. There is also anincreasing demand for heart failure services andarrhythmia detection, particularly atrial fibrillation foranticoagulation to prevent stroke (a priority <strong>of</strong> the DH’sQuality, Innovation, Productivity and Prevention(QIPP) programme). Care for congenital heart diseasein both children and adults should be organisedaround regional networks led by congenital cardiaccentres. Access to adequate pacing services andimplantation <strong>of</strong> complex devices could be improved.Particularly challenging issues involve the developmentand maintenance <strong>of</strong> high-quality informationtechnology and transfer services, as well as developingcardiology imaging services as recommended inBox 1.Maintaining and improving the quality<strong>of</strong> careThe recurrent cycles <strong>of</strong> national audits for heart disease,which have been increasingly comprehensive, have ledto improvements both in practice (eg <strong>with</strong> the movefrom hospital thrombolysis to pre-hospitalthrombolysis or PPCI) and <strong>of</strong> the audit tools thatcomplement the MINAP. The National Institute forClinical Outcomes Research (NICOR) now hostsMINAP, the British Cardiovascular InterventionsSociety (intervention), the SCTS (surgery) and the52 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Cardiovascular medicineBox 1 Quality tools, service frameworks and progress reports (www.improvement.nhs.uk/heart)NHS Improving Quality (NHS IQ) – now hosted by NHS England (previously National Commissioning Board)Event presentationsHeart improvement national cardiac conference (March 2010): ten years <strong>of</strong> the coronary heart disease (CHD)NSF. Presentation by Pr<strong>of</strong>essor Roger Boyle CBE, former national director for heart disease and stroke,Department <strong>of</strong> Health.Documents for sharingNational Imaging Board. Cardiac imaging: a report from the National Imaging Board. Department <strong>of</strong> Health,March 2010.NHS National End <strong>of</strong> Life Care Programme. End <strong>of</strong> life care in heart failure: a framework for implementation.NHS, June 2010.Strategic Commissioning Development Unit (SCDU). Commissioning pack for cardiac rehabilitation.Department <strong>of</strong> Health, October 2010.National Institute for Health and Care Excellence. Chronic heart failure. Quality Standards QS9. NICE, June2011.Latest publications in priority areas Quality, innovation and value in cardiac rehabilitation: commissioning for improvement. NHS Improvement,May 2012. National Heart Failure Audit 2011/12. November 2012. GRASP-AF report, published in Heart online. February 2013.British Congenital Cardiac Association (congenital)audits, and NACR (rehabilitation) and others will alsobe hosted in due course.The development <strong>of</strong> DH’s Quality Accounts in 2010 andthe use <strong>of</strong> Commission for Quality and Innovation(CQUINN) and other measures in the new outcomesframework in England will still hopefully facilitatefurther audit development to maintain standards <strong>of</strong> ahigh-quality service and sustain progress. Leadershiproles <strong>with</strong>in NHS Improvement Heart team andcardiovascular networks have been used to drive serviceimprovement and share best practice. The peer reviewprocess <strong>of</strong> the BCS has contributed to what is now theCare Quality Commission.Education and trainingEducation and training are essential at all levels, from<strong>patients</strong> and carers to undergraduates, foundationdoctors and specialist trainees in medicine. Mostcardiologists are involved in teaching students <strong>of</strong> clinicalmedicine and all grades <strong>of</strong> junior doctor, particularlythose in higher specialist training in cardiology in theirone <strong>of</strong> 17 deaneries. Designated trainers will havespecial responsibility for the supervision <strong>of</strong> registrarsand an increasing workload to provide evidence <strong>of</strong> theirtrainees’ competence through workplace-basedassessments. Cardiology-supported implementation <strong>of</strong>the Tooke review ensures a formal selection process atentry to specialist training, and has pioneered a nationalapplication process and developed a knowledge-basedassessment (KBA) for use in formative training.Cardiology encourages all trainees to undertake aperiod <strong>of</strong> research, and the BHF has expanded fundingfor such opportunities to encourage academic training.Formal training programmes are organised by higherspecialty training committees and the BCS organises anannual review course at the RCP <strong>with</strong> the Mayo Clinic.The BCS has elected vice-presidents for education andresearch, and for training, the latter being theincumbent chair <strong>of</strong> the specialist advisory committee(SAC) for cardiology. The vice-president for trainingholds delegated responsibility through the Physicians’Training Board from the General Medical Council forsetting standards for higher specialist training in thespecialty, and the deaneries organise annual reviews <strong>of</strong>competence which are externally verified throughassessment in the penultimate year. The cardiologycurriculum has recently been updated to include newC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 53


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>areas <strong>of</strong> practice such as cardiac computed tomographyand more generic areas such as medical leadership.Paediatric cardiology has its own Certificate <strong>of</strong>Completion <strong>of</strong> Training (CCT) and SAC <strong>with</strong> a recentlyupdated curriculum. Possible subspecialties includefetal cardiology. Care <strong>of</strong> adult congenital heart disease(ACHD) is open to trainees in paediatric or adultcardiology in 1–2 years <strong>of</strong> ACHD, depending on theultimate level <strong>of</strong> service.Mentoring and appraisal <strong>of</strong> medical and otherpr<strong>of</strong>essional staffAnnual appraisal, assessment <strong>of</strong> contribution toimproving quality and <strong>working</strong> towards revalidation isan increasing responsibility for consultant cardiologists.Mentoring <strong>of</strong> junior consultant colleagues, as well asjunior doctors, is also increasing. Mentoring forpr<strong>of</strong>essionals allied to medicine also helps to develop ahighly skilled, clinically competent group <strong>of</strong> healthcareworkers who will contribute to the delivery <strong>of</strong>high-quality cardiovascular care.Continuing pr<strong>of</strong>essional developmentContinuing pr<strong>of</strong>essional development (CPD) forcardiologists is regulated by the Federation <strong>of</strong>the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK, and isprovided by the BCS, which is now accredited by theEuropean Board for Accreditation in Cardiology(EBAC), through its annual scientific meeting, theEducationinheartseries and European Society <strong>of</strong>Cardiology textbook.Clinical governanceCardiology has been at the forefront <strong>of</strong> development <strong>of</strong>clinical governance at both national and local levels (seeabove, and Specialty and national audit below).Research – clinical studies and basic scienceThe British Society for Cardiovascular Research (BSCR)is an affiliated group <strong>of</strong> the BCS that recognises theimportance <strong>of</strong> basic science. It recently held its annualscientific conference jointly <strong>with</strong> BCS. Nationally,clinical and basic science research is supported by theBHF through project grants, chairs, and senior,intermediate and junior fellows. The medicaldirector <strong>of</strong> the BHF is a member <strong>of</strong> the council <strong>of</strong> theBCS. <strong>Consultant</strong> cardiologists are encouraged toconduct high-quality research individually and incollaboration <strong>with</strong> their whole-time academiccolleagues. There should be encouraged activeengagement <strong>with</strong> the new academic health sciencenetworks.Local management duties and regional andnational workA consultant may be the clinical director or hold someother leadership or management role <strong>with</strong>in the healthservice, NHS trust, network or clinical senate.Alternatively, she or he may be elected to the deanery’shigher specialist training committee.The BCS is run on a day-to-day basis by the presidentelect,secretary, assistant secretary, treasurer and chair <strong>of</strong>the Programme Committee. Affiliated groups addressthe subspecialty areas <strong>of</strong> echocardiography, nuclearcardiology, heart failure, intervention, pacing andelectrophysiology, congenital heart disease andrehabilitation, and they represent pr<strong>of</strong>essional groups <strong>of</strong>cardiac nurses, cardiac physiologists and primary care.Council representatives also represent colleagues fromthe DGHs, female cardiologists and <strong>patients</strong>. The BCSalso has a system <strong>of</strong> regional representatives andnetwork advisers. The Joint Specialty Committeeprovides an essential link between the RCP and BCS.In England, the NHS Improvement Heart team, thenational director and clinical leads/advisers haveprovided the impetus for change <strong>with</strong>in the specialtyover the last decade. Wales, Scotland and NorthernIreland have also developed programmes for improvingservices.Specialty and national guidelinesCardiology practice has responsibility for theobservation <strong>of</strong> multiple clinical guidelines,interventional procedure guidelines, technologyappraisals and other advice issued by NICE. Table 2includes additions to previous summaries from 2008edition <strong>of</strong> <strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>. 9As a constituent member, the BCS endorses andsupports guidelines published by the European Society<strong>of</strong> Cardiology.Specialty and national auditNICOR now hosts MINAP, BCIS, SCTS and BritishCongenital Cardiac Association (see above). Althougheach audit looks at a specific aspect <strong>of</strong> heart disease,they can be linked together to follow a patient’streatment and outcomes throughout their lifetime. Thisdoes not depend on where the patient receivedtreatment, who provided their care or what treatmentthey received. NACR works <strong>with</strong> the NHS Information54 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Cardiovascular medicineTable 2 Guidelines from the National Institute for Health and Care Excellence 2008–2012(http//guidance.nice.org.uk/)Clinical guidelinesProphylaxis against infective endocarditisCardiovascular risk assessment and modification <strong>of</strong> blood lipidsDiagnosis and initial management <strong>of</strong> acute stroke and transient ischaemic attack (TIA)Identification and management <strong>of</strong> familial hypercholesterolaemiaUnstable angina and non-ST segment elevated myocardial infarction (NSTEMI)Chest pain <strong>of</strong> recent onsetHypertensive disorders during pregnancyChronic heart failureStable anginaHypertensionMarch 2008 (CG64)May 2008 (CG67)July 2008 (CG68)August 2008 (CG71)March 2010 (CG94)March 2010 (CG95)August 2010 (CG107)August 2010 (CG108)July 2011 (CG126)August 2011 (CG127)Interventional procedure guidelinesTranscatheter aortic valve implantation for aortic stenosisThoracoscopic epicardial radi<strong>of</strong>requency ablation for atrial fibrillation (AF)Percutaneous epicardial catheter radi<strong>of</strong>requency ablation for AFPercutaneous epicardial catheter radi<strong>of</strong>requency ablation for ventricular tachycardiaPercutaneous laser revascularisation for refractory angina pectorisPercutaneous mitral valve leaflet repair for mitral regurgitationTranscatheter endovascular closure <strong>of</strong> perimembranous ventricular septal defectPercutaneous occlusion <strong>of</strong> left atrial appendage for non-valvular AFPercutaneous closure <strong>of</strong> patent foramen ovale (PFO) for recurrent migrainePercutaneous closure <strong>of</strong> PFO for prevention <strong>of</strong> paradoxical emboliJune 2008 (IPG266)January 2009 (IPG286)March 2009 (IPG294)March 2009 (IPG295)May 2009 (IPG302)August 2009 (IPG309)March 2010 (IPG336)June 2010 (IPG349)December 2010 (IPG370)December 2010 (IPG371)Technology appraisalsDrug-eluting stents for the treatment <strong>of</strong> coronary artery diseaseDabigatran etexilate for the prevention <strong>of</strong> venous thromboembolism after hip or knee replacementDabigatran etexilate in AFPrasugrel for treatment <strong>of</strong> acute coronary syndromes <strong>with</strong> percutaneous coronary interventionDronedarone for treatment <strong>of</strong> non-permanent AFClopidogrel and modified-release dipyridamole for prevention <strong>of</strong> occlusive vascular eventsIvabradine for the treatment <strong>of</strong> chronic heart failureJuly 2008 (TA152)September 2008 (TA157)March 2012 (TA249)October 2009 (TA182)August 2010 (TA197)December 2010 (TA210)November 2012 (TA267)Public health guidancePrevention <strong>of</strong> cardiovascular disease at the population levelJune 2010 (PH25)C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 55


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Centre. Our national audits against the above standardshave already provided key evidence on which to basefurther cost-effective service improvements andimprovements in patient outcomes.6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialty<strong>Consultant</strong> cardiologists increasingly work in teams toprovide a specialised cardiology inpatient service<strong>with</strong>out involvement in acute medicine commitmentsother than the care <strong>of</strong> <strong>patients</strong> in the predominantlycardiac portion <strong>of</strong> the emergency ‘take’ <strong>of</strong> the cardiaccare unit and the continuing care and heart failurewards. Importantly, they provide a consultation serviceto other specialists (as described in sections 2 and 4).Their patient numbers exceed 500 per annum, and wardor front-door emergency consultations may beunderestimated.Outpatient workMost cardiologists will hold one to two outpatientclinics per week. These will include new <strong>patients</strong> andfollow-up <strong>patients</strong>, <strong>with</strong> numbers as recommended bythe RCP and BCS. They will also hold specialistoutpatient clinics, increasingly on a one-stop basis, fornew <strong>patients</strong> who present <strong>with</strong> chest pain,breathlessness or suspected heart failure, murmurs andvalve disease, arrhythmia or syncope. Specialistoutpatient follow-up clinics will also carry out thefollowing activities (see Table 1): follow-up <strong>of</strong> <strong>patients</strong> <strong>with</strong> pacemakers and otherdevices, arrhythmias, valvular disease and cardiacdisease in pregnancy follow-up <strong>of</strong> <strong>patients</strong> after myocardial infarction andPCI (an opportunity to integrate <strong>with</strong> cardiacrehabilitation – see section 7) monitoring heart failure requiring specialist input.Specialist investigative and therapeuticproceduresMost consultant cardiologists will directly undertake,supervise and report laboratory procedures (seeTable 1).Specialist on callProvision <strong>of</strong> an on-call consultation service requires aminimum <strong>of</strong> six consultants. Ten are preferred to coverleave. The provision <strong>of</strong> a cardiac catheterisationlaboratory service around the clock, 7 days a week (as isneeded for PPCI) also requires specialised cardiacnurses, physiologists and radiographers.Other specialist activity and activities beyond thelocal servicesMost cardiologists have developed an area <strong>of</strong> specialinterest, such as imaging, heart failure, GUCH,electrophysiology or PCI. They are expected to provideevidence <strong>of</strong> the quality <strong>of</strong> such work through appraisal,CPD and membership, and by contribution to therelevant affiliated groups <strong>of</strong> the BCS. Attendance atregional, national and international meetings isexpected. Appropriate engagement in clinical senates tosupport networks is advised.Clinically related administration: timely andappropriate communicationWorking in a multidisciplinary environment andcontributing to local cardiac networks and patientpathways to improve healthcare delivery are all part <strong>of</strong>the clinical duty <strong>of</strong> a cardiologist. The interdisciplinaryliaisondetailedinsection4isanobligation.Balance <strong>of</strong> clinics, wards, acute and specialty careMost consultant cardiologists undertake all <strong>of</strong> theseactivities, and therefore will have an individualisedbalance <strong>of</strong> these activities in their personal job plans.They will make allowance for on-call duties and theneeds <strong>of</strong> the particular trust and cardiology service.Some consultants may be designated <strong>with</strong> responsibilityfor certain interdisciplinary work.Direct work compared <strong>with</strong> supervisionand teamworkCardiology is fundamentally a team-based specialty.<strong>Consultant</strong>s provide leadership to trainees, physiologistsand extended-role practitioner nurses who may delivercertain aspects <strong>of</strong> the service, but consultants engagedirectly in many activities themselves.Work in hospitals and the communityCardiac network pathways have developed to span thecommunity, the primary/secondary care interface andsecondary/tertiary inter-hospital transfers, and sharegood practice. Cardiologists need to clinically manageacute pathways, adult and paediatric coronary careunits, cardiac wards, cardiac physiology departments,cardiac catheter laboratories and rehabilitation services.They may be engaged in community clinics to ensuresafe referral practice, <strong>with</strong> cardiovascular disease stillrepresenting the most common cause <strong>of</strong> mortality.There are also cardiac networks in place in Wales andNorthern Ireland.56 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Cardiovascular medicine7 Opportunities for integrated careCardiac networks are a reflection <strong>of</strong> the major progressthat has been made in integrating cardiac care over thelast decade. 1 Once care pathways are clearly defined,further opportunities for integrated care may berecognised and made cost-effective under the QIPPprogramme: one-stop clinics for more firstconsultations, initial investigations and counselling;joint GUCH/adult and paediatric/cardiology localclinics <strong>with</strong> a significant educational focus; in-reachcommunity heart failure teams to help support heartfailure <strong>patients</strong> admitted to hospital; or progressivepatient involvement in MDT meetings about care.There is a need for vigilance around the new strategicclinical networks (SCNs) to ensure no dilution <strong>of</strong>impact as the model is extended to other specialties.8 Workforce requirements for the specialtyCurrent workforce numbersThe NHS electronic staff records identified 855consultant cardiologists (whole-time equivalent (WTE):825) in May 2010. There were 580 trainees according toa recent BCS survey, <strong>with</strong> 980 consultants in England,and 1,200 across UK. Around 12% <strong>of</strong> consultants and21% <strong>of</strong> trainees are women, and their recruitment isencouraged to the specialty. There are currently only90 paediatric cardiologists.Number <strong>of</strong> consultants needed to provide aspecialist service for a population <strong>of</strong> 250,000The BCS has estimated 10 that the UK requires acontinuing increase in numbers <strong>of</strong> consultantcardiologists (including at least three paediatricconsultants) per million <strong>of</strong> the population to providecomprehensive cardiac services. For a population <strong>of</strong>250,000, no less than a 1:6 on-call ratio should be aimedfor, <strong>with</strong> more subspecialist consultant cardiologistsrequired for secondary, tertiary and community cardiaccare. Because <strong>of</strong> PPCI, more interventionalists are nowrequired. Similarly, the new chest pain guidelines willresult in the need for more imagers. The currentpriorities <strong>of</strong> cardiac rehabilitation and heart failureshould also be recognised in programmed activities(PAs) allocation in job plans for consultants.National workforce requirementsOnly 25% <strong>of</strong> consultant cardiologists now undertakeacute medicine. The estimated number <strong>of</strong> consultantcardiologists required does not include those <strong>with</strong>Table 3 Typical weekly job plan for a consultantcardiologistActivityDirect clinical careProgrammedactivities(PAs)In<strong>patients</strong> (CCU, ward rounds, referrals) 1.5–2.0Out<strong>patients</strong> (plus additional outreach forpaediatric cardiologists)Laboratory work (or other specialised clinicalwork)Meetings <strong>of</strong> the MDT (PCI, cardiac surgery,imaging, arrhythmia)2.0 (+ 2.0)2.0–3.00.5Clinical administration 1.0On call 0.5Total 7.5–9.5Supporting clinical careClinical management, audit, clinicalgovernance, service improvement anddevelopment, teaching, CPD, research,advisory appointments committees, work forexternal organisations for the greater good<strong>of</strong> the NHS2.5CCU = cardiac care unit; CPD = continuing pr<strong>of</strong>essional development;MDT = multidisciplinary team; PCI = percutaneous coronaryintervention.responsibilities for acute medicine or academicmedicine, nor does it take account <strong>of</strong> the more recentpriorities as described above.9 <strong>Consultant</strong> work programme/specimenjob planTable 3 outlines the typical work programme <strong>of</strong>consultants undertaking cardiovascular medicine.10 Key points for commissioners1 The principle <strong>of</strong> <strong>working</strong> together, enshrinedin the RCP/BCS response to the NHS White PaperEquity and excellence: liberating the NHS, 11has been upheld by all health pr<strong>of</strong>essionalopinions. The implementation <strong>of</strong> the Health andSocial Care Bill 2012 demands vigilance undergovernance.2 An essential building block includes liaison at localvascular/chronic disease management board levelC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 57


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>between the local cardiology service and primarycare clinical commissioning groups. The new CVDOutcomes Strategy 2013 will emphasise anintegrated model <strong>of</strong> all cardiovascular care <strong>with</strong>prevention and rehabilitation.3 There should be agreed care pathways for cardiacconditions across the local health economy and thelarger cardiovascular, paediatric and GUCHnetworks. For instance, future commissioningrequirements are likely to mandate screening by apaediatrician <strong>with</strong> an interest in cardiology prior toreferral to a cardiologist in congenital heart disease.4 Commissioners (NCB and CCGs) should committo reviewing, through the specialty’s clinicalreference group and local senates/networks,achievements in national cardiac audits, both those<strong>with</strong>in NICOR, and those <strong>with</strong>out (eg NACR),together <strong>with</strong> local mortality trends, in settingpriorities.5 Cardiovascular networks are recognised tohave provided a key (and improving) relationship<strong>with</strong> commissioning. A very successful exampleis the network-based roll-out <strong>of</strong> PPCI andsubsequent cardiac rehabilitation pathwayreview. 1,126 Service level agreements should define expectedoutcomes to meet national cardiac auditoutcomes and standards (see point 4 above andBox 1).7 Priority investment in development, delivery andintegration <strong>of</strong> heart failure, cardiac rehabilitation,palliative care and arrhythmia services should bebalanced <strong>with</strong> a reduction and decommissioning <strong>of</strong>others, <strong>with</strong>out destabilising any aspect <strong>of</strong> care,whether acute or long term, or causingdisadvantage to <strong>patients</strong>.8 There should be a sustainable mechanism for input<strong>of</strong> the specialty standards <strong>of</strong> the RCP and BCS,including those <strong>of</strong> affiliated groups, <strong>with</strong> <strong>patients</strong>through CCP UK, via the Joint SpecialtyCommittee/Specialty clinical reference group in thecommissioning process.9 It is hoped that the NHS Commissioning Board inEngland and planning mechanisms for devolvednations will utilise cardiology’s innovativeapproaches to development and acknowledgerelevant informative reports 5,6,7,13 in specialisedand local commissioning.10 A new Strategic Commissioning Development Unit(SCDU) Department <strong>of</strong> Health model <strong>of</strong>commissioning guide, pioneered for Cardiacrehabilitation (October 2010, see Box 1),provides a model for future commissioning <strong>of</strong>services. 13References1 NHS Improvement-Heart. Growth <strong>of</strong> primary PCI forthe treatment <strong>of</strong> heart attack <strong>patients</strong> in England2008–2011: therole<strong>of</strong>NHSImprovementandthecardiacnetworks. www.improvement.nhs.uk/heart2 NHS Specialised Services. Review <strong>of</strong> children’s congenitalcardiac services in England, July 2012. Judicial review,February 2013.www.specialisedservices.nhs.uk/safeandsustainable3 Department <strong>of</strong> Health. National service framework forcoronary heart disease. London: DH, 2000.4 Fifth report on the provision <strong>of</strong> services for <strong>patients</strong> <strong>with</strong>heart disease. Heart 2002;88(Suppl III):iii1–59.www.heart.bmj.com [Accessed 25 April 2013]5 Cardio & Vascular Coalition. Destination 2020. A plan forcardiac and vascular health. The voluntary sector vision forchange. London: British Heart Foundation, 2009.www.cardiovascularcoalition.org.uk6 Oxford Healthcare Associates. Access to cardiac care in theUK. A report on invasive procedures in cardiac conditions.Recent trends, variations in access and future need.BritishCardiovascular Society and British Heart Foundation,2009.7 Ray S for British Cardiovascular Society. Commissioning<strong>of</strong> cardiac services – a resource pack from the BCS.London:BCS, 2011.8 Department <strong>of</strong> Health. National service framework forcoronary heart disease – chapter eight: arrhythmias andsudden cardiac death. London: DH, 2005.9 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. <strong>Consultant</strong> <strong>physicians</strong><strong>working</strong> <strong>with</strong> <strong>patients</strong>: the duties, responsibilities andpractice <strong>of</strong> <strong>physicians</strong> in medicine, 4th edn. London: RCP,2008.10 Hackett, D. Cardiac workforce requirements in the UK.London: British Cardiovascular Society, 2005.www.bcs.com11 Department <strong>of</strong> Health. Equity and excellence: liberatingthe NHS. London: Stationery Office, 2010.12 Shahid M, Varghese A, Moqsith A et al.Survey<strong>of</strong>cardiacrehabilitation across the English cardiac networks2007–2009. Br J Cardiol 2011;18:33. www.bjcardio.co.uk13 NHS Improvement-Heart rehabilitation team. Quality,innovation and value in cardiac rehabilitation:commissioning for improvement. www.improvement.nhs.uk/ePublications/cardiacrehab/files/html5/index.html58 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Clinical geneticsClinical geneticsPeter D Turnpenny FRCP FRCPCH FRCPath FHEA <strong>Consultant</strong> clinical geneticistFrances A Flinter MD FRCP FRCPCH <strong>Consultant</strong> in clinical genetics1 Description <strong>of</strong> the specialtyClinical genetics provides a diagnostic and geneticcounselling service for individuals and families <strong>with</strong>,or at risk <strong>of</strong>, conditions that have, or may have, a geneticbasis. Individuals and families are helped to understandtheir condition, its implications and their options <strong>with</strong>regard to reproduction, screening, prevention andmanagement. Genetic disorders affect at least 5% <strong>of</strong> thepopulation. 1Who are the <strong>patients</strong>?A patient is an individual person, or their family,affected by or at risk <strong>of</strong> a genetic disorder or congenitalabnormality (that may be non-genetic). They seek adiagnosis, information, recurrence risks for themselvesor other family members, screening and interventionoptions. Patients come from all age groups.Main disease patternsGenetic disorders can affect any body organ or systemand include: chromosomal abnormalities, including balancedrearrangements single gene disorders, eg muscular dystrophies,dysmorphic syndromes, inherited cardiacconditions, skeletal and connective tissue disorders,and neurological conditions, across all ages familial cancer syndromes, including commoncancers as well as rare single-gene conditions congenital abnormalities, including non-geneticand teratogenic anomalies learning disabilities.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceThis is regionally based for populations ranging fromapproximately 1 million to 5 million and delivered in a‘hub and spoke’ model. 2 Each centre maintains acomputerised family-based record system,incorporating disease-specific registers.Staff consultant clinical geneticists, <strong>with</strong> subspecialtyinterests, eg paediatrics/dysmorphology, cancer,neurogenetics, prenatal and cardiac genetics genetic counsellors (GCs), <strong>of</strong>ten <strong>with</strong> subspecialtyinterests, perhaps based in a peripheral <strong>of</strong>fice specialty registrars (StRs) and academic clinicalfellow (ACF) trainees administrative, clerical and managerial staff information technology (IT) support.Service delivery mainly outpatient-based <strong>with</strong> widely distributedlocal clinics general and specialist clinics, eg paediatric, cancer,neurogenetics and cardiac- combined clinics, eg ophthalmic, skeletal dysplasiaand cardiac.Service summaryThis includes clinical and genetic diagnosis; explanationand information about the disease, syndrome orcondition; determination and communication <strong>of</strong>genetic/recurrence risk; identification <strong>of</strong> screeningand/or intervention options; and appropriatecounselling support. 3 Additionally, there is an expertinformation and educational resource for healthcaredisciplines, 4 a contribution to research through clinicaland molecular projects, and recruitment to nationalstudies and therapeutic trials.Sources <strong>of</strong> referral from primary, secondary andtertiary levelsReferrals come from all medical specialties, mostcommonly general practice, paediatrics,obstetrics/antenatal screening, surgery and cardiology.Referrals may be urgent, eg neonatal consultations, andreceived from other regional genetic centres (RGCs)C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 59


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>because families are widely scattered. Self-referrals areusually accepted and additional family members <strong>of</strong>tenattend unannounced.The NHS document Do once and share: clinical genetics(2006) 5 outlines the patient journey.Locality-based and/or regional servicesThereare23RGCsintheUK,all<strong>with</strong>stronglinkstogenetics laboratories, mainstream medical specialtiesandtheirclinicalnetworks;servicesaredeliveredina‘hub and spoke’ model.Community models <strong>of</strong> careThe Department <strong>of</strong> Health (DH) genetics white paper(2003) 6 recognised that genetics impacts on mainstreammedical services. The DH in England funded severalinitiatives (for details see www.clingensoc.org)andsome general practitioners <strong>with</strong> a special interest(GPwSIs) were appointed. The role <strong>of</strong> GPwSIs remainsto be evaluated fully and debate continues in relation tothe extent to which genetics can be ‘mainstreamed’ (seesection 10, Key points for commissioners, no 9).Complementary servicesIn some areas hereditary blood diseases(haemoglobinopathies/haemophilias) are <strong>of</strong>tenmanaged by haematologists.Some clinicians (not trained as geneticists) <strong>with</strong> aspecialised area <strong>of</strong> expertise undertake the clinicalgenetic aspects <strong>of</strong> a condition, or group <strong>of</strong> conditions,and <strong>of</strong>fer a national or supra-regional service, egmitochondrial disorders.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong> Some referrals are managed by a GC, possiblyunder consultant supervision. Background information is gathered – including adetailed family pedigree, confirmation <strong>of</strong> diagnoses(eg from cancer registry), review <strong>of</strong> medical recordsand psychosocial circumstances. The consultant clinic includes assessment,examination, explanation, counselling, appropriateinvestigations and/or screening. Follow-up may be undertaken by a GC. Postclinic letters are detailed and copied to thepatient/family – this is regarded as a key part <strong>of</strong>patient communication and is intended forlong-term retention. Seealsosections1and2.Patient-centred careThe patient’s, or family’s, agenda is paramount;questions are explicitly invited. Genetic counselling is‘person-centred’ and ‘non-directive’ and clinical lettersare personalised.Principles <strong>of</strong> privacy, consent, confidentiality andnon-discrimination on the basis <strong>of</strong> geneticcharacteristics are upheld – see Consent andconfidentiality in genetic practice. 7Involving <strong>patients</strong> in decisions about theirtreatmentPatients/families are provided <strong>with</strong> accurate, up-to-dateinformation on genetic risks, testing and/or screening,and reproductive choices available. A non-directiveapproach fosters patient autonomy and they areencouraged to retain clinic letters. The specialposition <strong>of</strong> children has been extensively considered 8and the principles <strong>of</strong> the Mental Capacity Act 2005 9upheld.Patient choice: ethnic and religious considerationsEthnic, cultural and religious considerations areparamount and translation services are used whennecessary.Opportunities for educationThese are provided at clinic through postclinic lettersand patient information leaflets (in different languages).Patients and families are directed to relevant lay supportgroups, and geneticists respond to invitations to theirmeetings.Promoting self careA non-directive approach and autonomous decisionmaking are encouraged (see above).Patients <strong>with</strong> chronic conditionsClinical geneticists actively help coordinatemultidisciplinary care.The role <strong>of</strong> the carerThe carer’s role is recognised to be vital for many<strong>patients</strong>, especially those <strong>with</strong> a learning disability andneuromuscular disorders. Advocacy and support are<strong>of</strong>fered appropriately.60 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Clinical geneticsPatient support groupsClose links exist <strong>with</strong> many relevant patient groups,and clinical geneticists are well represented amongtheir expert advisers. Close links also exist <strong>with</strong> theGenetic Alliance (umbrella organisation <strong>of</strong> laysupport groups).Availability <strong>of</strong> clinical records/resultsRecords are accessible under the Data Protection Act1998, <strong>with</strong> care taken not to disclose information heldabout other family membersRole <strong>of</strong> expert patientThis is fully acknowledged; <strong>with</strong> mutual consent,<strong>patients</strong> may be put in touch <strong>with</strong> others similarlyaffected.Communication <strong>with</strong> <strong>patients</strong>The aim is to be prompt, clear and sensitive.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>The clinical genetics service links <strong>with</strong> GCs, who havea background in nursing or science <strong>with</strong> specialisttraining. The Association <strong>of</strong> Genetic Nurses andCounsellors (AGNC) is registered <strong>with</strong> the HealthPr<strong>of</strong>essions Council 10 and there is a very closeintegrated <strong>working</strong> practice between clinical geneticistsand GCs (see report 11 ). There is also close liaison <strong>with</strong>laboratory scientists – biochemical, molecular andcytogeneticists – <strong>with</strong> routine combined meetings.Working <strong>with</strong> other specialtiesClinical geneticists are valued members <strong>of</strong> clinicalnetworks, eg cancer/oncology, fetal medicine andcardiology. Advice is provided on familial/geneticdiseases and genetic testing. There are combined/jointclinics, eg ophthalmic, prenatal (fetal medicine) andcardiac genetics (eg Marfan syndrome). Joint reports<strong>of</strong> the Clinical Genetics Society (CGS) <strong>with</strong> theAssociation <strong>of</strong> British Neurologists 12 and the <strong>Royal</strong><strong>College</strong> <strong>of</strong> Obstetricians and Gynaecologists 13 highlightthe importance <strong>of</strong> joint <strong>working</strong> practices.Working <strong>with</strong> GPs and GPs <strong>with</strong> a specialinterest (GPwSIs)Referral guidelines are available to assist GPs in clinicalmanagement, eg for family history <strong>of</strong> common cancers.These may be national guidelines, eg National Institutefor Health and Care Excellence (NICE) guideline onfamilial breast cancer, or local guidelines. Some GPwSIswere established <strong>with</strong> white paper funding 4 andclinical geneticists <strong>of</strong>ten teach at GP study days.Other specialty activity beyond local servicesNational forums exist to discuss difficult diagnostic,ethical or management problems. These have regularmeetings and include the following: UK Dysmorphology club – quarterly meetings;similar regional events GenEthics club (informal forum to discuss ethicallydifficult cases) – meets three times a year to discussdifficult ethical cases and issues smaller special interest group meetings, eg paediatricneurogenetics multicentre regional meetings for audit andtraining, eg South West <strong>of</strong> Britain group (six RGCs)meets three times a year annual national conferences – CGS, AGNC, CancerGenetics Group and British Society <strong>of</strong> HumanGenetics.5 Delivering a high-quality serviceQuality standards for clinical genetic services includethe following: applying principles <strong>of</strong> ‘good medical practice’ 14 toclinical genetics and giving time to clinicalgovernance giving attention to detail and accuracy in diagnosis –the key to high-quality genetic counselling adherence to quality standards documents 3,15 the Genetics Commissioning Advisory Group(GenCAG) have produced auditable qualitystandards for commissioning, 16 including promptpostclinic letters and response to urgent referrals,eg prenatal cases service should be part <strong>of</strong> an RGC, <strong>with</strong> access tospecialised genetic laboratories and academicuniversity departments <strong>of</strong> medical genetics (seereference 17 for requisite facilities).Maintaining and improving the quality <strong>of</strong> careThe following activities help maintain and improve thequality <strong>of</strong> care: patient satisfaction surveys and local, regional andnational auditsC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 61


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> clinical review meetings <strong>with</strong>in RGCs andinter-centre case-note peer reviews national steerage from the clinical governancecommittee <strong>of</strong> the CGS.Service developments that improve patient care establishment <strong>of</strong> clinical networks for expandingsubspecialty demand, eg cardiac genetics regular development and updating <strong>of</strong> care pathways implementation <strong>of</strong> new diagnostic tools, egmicroarray comparative genomic hybridisation(array-CGH), in collaboration <strong>with</strong> laboratorycolleagues.Education and training Entry to four years <strong>of</strong> clinical genetics at StR gradeis at specialty training year 3 (ST3) level after coremedical training. Membership <strong>of</strong> the <strong>Royal</strong> <strong>College</strong><strong>of</strong> Physicians (MRCP(UK)), or the member <strong>of</strong> the<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Paediatrics and Child Health(MRCPCH), must be attained prior to entry. Up to12 months <strong>of</strong> training spent in pre-agreed research,such as a PhD, or in a locum appointment fortraining (LAT) post may be recognised. Most training programmes involve rotation throughblocks specialising in different areas such asdysmorphology, cancer genetics, neurogenetics,cardiac genetics, prenatal genetics, research andspecial interest. From 2012, trainees will take a specialty certificateexamination or a diploma <strong>of</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong>Pathologists.Mentoring and appraisal <strong>of</strong> medical and otherpr<strong>of</strong>essional staffA consultant clinical geneticist will appraise fellowconsultants, junior doctors and genetic counsellors, aswell as undergoing their own annual appraisal.Continuing pr<strong>of</strong>essional developmentThis is an academic specialty and rapid developments ingenetic science make adequate continuing pr<strong>of</strong>essionaldevelopment (CPD) essential, for which numerousopportunities exist. Job planning should allow foradequate CPD time. 18Clinical governanceThe following are routinely in place: care pathways and clinical protocols in place formany conditions; regularly audited regular departmental clinical meetings for casediscussion regular combined clinical-laboratory meetings.Research – clinical studies and basic scienceThis is considered essential. Many consultants conducttheir own clinical and laboratory collaborative projects,actively recruit <strong>patients</strong> for national and internationalstudies, and publish regularly. Genetics has a growingportfolio <strong>with</strong>in a comprehensive local researchnetwork as part <strong>of</strong> the National Institute for HealthResearch (NIHR). Those seeking an academic careercan train through an ACF post.Local management dutiesA consultant may be the lead clinician or the clinicaldirector or may hold other leadership or managementroles <strong>with</strong>in the service or NHS trust.Regional and national workBecause clinical genetics is a small specialty, a highproportion <strong>of</strong> consultants will therefore undertakecommittee work at a regional and/or national level.Examples <strong>of</strong> national committees are: the NationalScreening Committee, Human Genetics Commission,Human Genome Strategy Group, NICE and advisorygroups for national specialist services.Specialty and national guidelinesThe following guidelines are available: see CGS website (www.clingensoc.org) NICE guidelines for familial breast cancer 19 Scottish consortium pathway guidelines for themanagement <strong>of</strong> common genetic disorders andothers.Specialty and national auditLocal and regional audit projects are regularlyconducted in relation to specific diseases and serviceissues, and national audit projects are beingdeveloped. A regular inter-regional case note audit isundertaken.Quality tools and service frameworksQuality tools for clinical genetics are underdevelopment and genetics is mentioned in a number <strong>of</strong>national service frameworks (NSFs), eg cardiac services.62 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Clinical genetics6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialtyThe CGS has published a description <strong>of</strong> the work <strong>of</strong> aclinical geneticist in its 2011 document Roles <strong>of</strong> theclinical geneticist. 20 This includes: diagnosis <strong>of</strong> genetic disorders and congenitalmalformations investigation and genetic risk assessment information giving predictive genetic testing initiation and coordination <strong>of</strong> health surveillanceand screening for genetic conditions coordination <strong>of</strong> interventional management inspecialist or multidisciplinary clinics management <strong>of</strong> the extended family maintenance <strong>of</strong> genetic family registers liaison <strong>with</strong> genetic laboratories participation in local and national genetic networks education and training <strong>of</strong> genetic and otherhealthcare pr<strong>of</strong>essionals acting as an expert resource to all healthpr<strong>of</strong>essionals research – clinical, biomedical, psychosocial andservice related.Inpatient workThis is limited to ward consultations.Outpatient workSee section 3. <strong>Consultant</strong>s on full-time contracts(10 programmed activities (PAs)) undertake9–11 clinics per month, each consultation lasting45minutesonaverage,equatingtoanannualworkload<strong>of</strong> up to 400 formal outpatient consultations; 65–80%<strong>of</strong> these are new cases/families. <strong>Consultant</strong>s alsosupervise the caseload <strong>of</strong> GCs, who may conductapproximately 200 consultations annually that neverreach a consultant clinic.Specialist investigative and therapeuticproceduresPatients requiring specialist procedures are referred tothe appropriate specialists.Specialist on callSome centres <strong>of</strong>fer an on-call service for urgent advice,eg prenatal or ward consults, including neonatal units.Clinically related administrationAdministration related to clinical work includes thefollowing: maintenance <strong>of</strong> disease-specific registers,development <strong>of</strong> protocols and guidelines, andcontribution to clinical networks correspondence and organisation relating to familiesand their extended members.The balance between clinics, wards, acute andspecialty careThe balance <strong>of</strong> work is split as follows: mostly outpatient-based; each half-day clinicrequires an additional PA for preparation andcorrespondence the proportion <strong>of</strong> urgent referrals varies from centreto centre.Direct work compared to supervision andteamworkAlthough most <strong>of</strong> the work is direct, but supervision <strong>of</strong>both StR trainees and GCs would each require aminimum <strong>of</strong> 0.5 PA per week. 18,207 Opportunities for integrated careThe principles <strong>of</strong> integrated care are well-suited toclinical genetics because many genetic diseases aremultisystem, requiring a multidisciplinary approach.Geneticists are well placed to take a holistic,patient-centred approach, and coordinate involvement<strong>of</strong> other disciplines, screening as appropriate, andprovide expert information to other healthcarepr<strong>of</strong>essionals.8 Workforce requirements for the specialtyThe current workforce in England is approximately140 consultant clinical geneticists (data collected byCGS), and 59 StRs. The <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physiciansestimates that 0.75 whole-time equivalent (WTE)consultants are required per 250,000 population, whichequates to 7.5 consultant notional half days (NHDs) toprovide a specialist service (both general and cancergenetics) to this size population. Assuming a populationin England <strong>of</strong> 50 million, this equates to a consultantworkforce requirement <strong>of</strong> 150 WTE consultants.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 63


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 <strong>Consultant</strong> work programme/specimen job plan generated by a population <strong>of</strong> 250,000Activity Workload Programmed activities (PAs)Direct clinical careSupporting pr<strong>of</strong>essionalactivities (SPAs)Other NHS responsibilitiesExternal dutiesOutpatient clinics <strong>with</strong> preparation and dictation; follow-upcorrespondence, telephone and written advice; ward referrals;multidisciplinary team (MDT) meetings (direct clinical carecomponent); travel to clinics and to MDTs; andnurse/counsellor/StR supervisionEducation and training; appraisal; departmental managementand service development; audit and clinical governance; CPD andrevalidation; researcheg medical director/clinical director/lead consultant inspecialty/clinical tutoreg work for deaneries/royal colleges/specialist societies/DH orother government bodies, etc7.5–8.02.0–2.5Local agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trust9 <strong>Consultant</strong> work programme/specimenjob planTable 1 shows a consultant work programme/specimenjob plan.10 Key points for commissioners1 Clinical genetics is commissioned as a specialisedservice in England (Specialised services nationaldefinition set, definition no 20). 21 In devolvedregions: in Scotland clinical genetics iscommissioned by health boards, while the fourgenetics laboratories comprise the ScottishGenetics Consortium, commissioned by theNational Services Division, NHS National ServicesScotland; in Wales, genetics is commissioned by theHealth Care Commission Wales; in NorthernIreland, genetics is commissioned by the Healthand Social Services Boards (informed by theRegional Medical Services Consortium).2 The role <strong>of</strong> the specialty in contributing to clinicalcare in the NHS is far wider than direct patientcontact; expertise and education is provided acrossall aspects <strong>of</strong> medical genetics.3 Clinical genetics services are complex,multidisciplinary services based in RGCs,<strong>of</strong>fering integrated clinical and laboratory service,typically serving a population <strong>of</strong> 1–5 millionpeople.4 Staff providing these services include consultantclinical geneticists (0.75 WTE per 250,000population); registered genetic counsellors; andappropriate administrative, clerical, IT andmanagement support.5 Services <strong>of</strong>fered include the diagnosis <strong>of</strong> geneticconditions and birth defects that, althoughindividually rare, account for at least 5% <strong>of</strong> diseasein the population. Advice about appropriatescreening/surveillance is <strong>of</strong>fered, including torelatives at risk <strong>of</strong> being affected. Reproductiveoptions, including prenatal diagnosis orpre-implantation genetic diagnosis, are discussed,and <strong>patients</strong> and their families are directed toadditional sources <strong>of</strong> advice and support.6 RGCs should also include, or have access to,comprehensive laboratory services, includingmolecular genetics (DNA), cytogenetics(chromosomes) and specialised biochemistry(inborn errors <strong>of</strong> metabolism, etc). Clinicalinvolvement in the provision <strong>of</strong> laboratory servicesis essential to ensure clinically appropriate genetictesting and follow-up.7 Clinical genetics services uniquely support not onlythe person who initially presents to the geneticsclinic but also members <strong>of</strong> the extended family whomay also be at risk. Sometimes this follow-up workis facilitated by the maintenance and activecurating <strong>of</strong> disease-specific genetic registers.8 Genetics centres maintain long-term (sometimeslifelong) contact <strong>with</strong> <strong>patients</strong> and their familiesand retain clinical records indefinitely as theycontinue to be relevant to <strong>patients</strong>’ descendantsand succeeding generations.9 The explosion in genetic testing over the last fewyears will continue and the benefits <strong>of</strong> these testswill extend through all branches <strong>of</strong> medicine. Staff64 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Clinical genetics<strong>working</strong>inRGCsallocateconsiderabletimeto<strong>working</strong> <strong>with</strong> colleagues across the specialties inorder to ensure that the potential benefits <strong>of</strong>genetic testing are understood, made available to<strong>patients</strong> in all areas <strong>of</strong> medicine (so-called‘mainstreaming’), and ethically applied.10 The development <strong>of</strong> genetic predisposition tests(bothinNHSclinicsandcommercial‘direct-to-consumer’ tests) will increase thedemand on NHS genetic counselling services, as agreater proportion <strong>of</strong> <strong>patients</strong> will not have singlegene disorders or chromosome rearrangements butmore complex multifactorial problems.References1 Department <strong>of</strong> Health. Annual report <strong>of</strong> the Chief MedicalOfficer 2009. London: DH, 2010:38–45.2 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Commissioning clinicalgenetic services. London: RCP, 1998.3 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Clinical genetic services.Activity, outcome, effectiveness and quality. London:RCP,1998.4 House <strong>of</strong> Lords Science and Technology Committee.Genomic medicine. London: Stationery Office, 2009.www.publications.parliament.uk/pa/ld200809/ldselect/ldsctech/107/107i.pdf5 Temple IK, Westwood G. Do once and share: clinicalgenetics. London: National Health Service, 2006.www.bshg.org.uk/documents/<strong>of</strong>ficial docs/DOAS finalprinted report%5B1%5D.pdf6 Department <strong>of</strong> Health. Our inheritance, our future.Realising the potential <strong>of</strong> genetics in the NHS.London:DH, 2003.7 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Pathologistsand British Society for Human Genetics. Consent andconfidentiality in genetic practice: guidance on genetictesting and sharing genetic information. A report <strong>of</strong> theJoint Committee on Medical Genetics. London: RCP,RCPath, BSHG, 2011.8 Clarke A. The genetic testing <strong>of</strong> children. Report <strong>of</strong> a<strong>working</strong> party <strong>of</strong> the Clinical Genetics Society, UK. JMedGenet 1994;31(10):785–97.9 Mental Capacity Act 2005. www.legislation.gov.uk/ukpga/2005/9/contents10 SkirtonH,BarnesC,GuilbertP,KershawA.Recommendations for education and training <strong>of</strong> geneticnurses and counsellors in the United Kingdom. JMedGenet 1998;35(5):410–2.11 Clinical Genetics Society. Pr<strong>of</strong>essional roles in themultidisciplinary team in genetics. Aframeworkforpractice prepared by a <strong>working</strong> party <strong>of</strong> the ClinicalGenetics Society and the Association <strong>of</strong> Genetic Nursesand Counsellors. CGS, AGNC, April 2011.www.clingensoc.org/Docs/WP AGNC CGS v2.pdf12 Association <strong>of</strong> British Neurologists and Clinical GeneticsSociety. Genetic services for neurological disorders. Report<strong>of</strong> a <strong>working</strong> party <strong>of</strong> the Association <strong>of</strong> BritishNeurologists and Clinical Genetics Society. ABN, CGS,September 2003. www.clingensoc.org/Docs/GenetServices Neuro.pdf13 Clinical Genetics Society. Clinical genetics andantenatal/fetal medicine: liaison and training. Areport<strong>of</strong>the Clinical Genetics Society prenatal genetics group.December 2008. www.clingensoc.org/Docs/CGS-PGGfinal%20report Dec%2008.pdf14 General Medical Council. Good medical practice.London:GMC, 2006. www.gmc-uk.org/static/documents/content/GMP 0910.pdf15 Clinical Genetics Society. Clinical standards for a geneticsunit. The clinical governance sub-committee. August2005. www.clingensoc.org/Docs/Standards/ClinicalStandards.pdf16 Department <strong>of</strong> Health. Quality markers for clinicalgenetics services. London: DH, 2002.17 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Commissioning clinicalgenetic services. London: RCP, 1998.18 Clinical Genetics Society. Guide to consultant jobplanning: March 2011. www.clingensoc.org/Docs/CGS%20Job%20Planning 2011.pdf19 National Institute for Health and Care Excellence.Familial breast cancer. The classification and care <strong>of</strong>women at risk <strong>of</strong> familial breast cancer in primary,secondary and tertiary care: update. NICE clinicalguideline 41 (partial update <strong>of</strong> NICE clinical guideline14). London: NICE, 2006.20 Clinical Genetics Society. Roles <strong>of</strong> the clinical geneticist,March 2011. www.clingensoc.org/Docs/Roles%20Clinical%20Geneticist 2011.pdf21 Specialised services national definitions set (SSNDS), 3rdedition. Definition no 20: specialised medical geneticsservices (all ages). www.yhscg.nhs.uk/specialised-services-national-definition-set-version-3.htmNote to readers: This chapter has not been updated for the revised 5th edition 2013. The text has been reproduced from the 2011 edition.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 65


2 Specialties Clinical neurophysiologyClinical neurophysiologyDr Robin Kennett <strong>Consultant</strong> clinical neurophysiologistDr Rosalind Kandler <strong>Consultant</strong> clinical neurophysiologist1 Description <strong>of</strong> the specialtyClinical neurophysiology uses measurement <strong>of</strong> electricalactivity from the central and peripheral nervous systemto help in the diagnosis and management <strong>of</strong> a widerange <strong>of</strong> neurological conditions in all age groups. Mostconsultants work <strong>with</strong>in neuroscience centres, althoughsome services are delivered in district general hospitals(DGHs), and all departments are supported byhealthcare scientists (HCS). The core investigations areelectroencephalography (EEG) and nerve conductionstudies (NCS) <strong>with</strong> electromyography (EMG), whichare mostly performed on out<strong>patients</strong> and constitute thelargest part <strong>of</strong> clinical neurophysiology workload. EEGis used to investigate children and adults <strong>with</strong> epilepsy,the most common serious neurological condition, 1 andnerve conduction is required for the management <strong>of</strong>peripheral nerve disorders such as entrapmentneuropathy (carpal tunnel syndrome, ulnar neuropathy,etc) and generalised peripheral neuropathy (eg diabeticneuropathy). Clinical neurophysiology is used toinvestigate a wide range <strong>of</strong> less common neurologicaldiseases, and most departments also perform long-termEEG monitoring to record episodic disorders(ambulatory EEG and video-telemetry), evokedpotentials for multiple sclerosis, and EMG forradiculopathy, muscle disease, myasthenia gravis andmotor neuron disease. Some departments <strong>of</strong>fer highlyspecialised investigations that may not be available in allneuroscience centres, including EEG monitoring onintensive therapy unit (ITU) for coma, intracranial EEGandevokedpotentialrecordingduringneurosurgeryforepilepsy, brain tumours, Parkinson’s disease and spinalsurgery, polysomnography to investigate sleepdisorders, and evoked potentials for retinal disease andhearing loss.The scope <strong>of</strong> clinical neurophysiology brings it intocontact <strong>with</strong> many other specialties including neurologyand neurosurgery, paediatrics, rheumatology andorthopaedics, plastic surgery, ophthalmology, generalmedicine and general practice.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralNeurophysiology testing requires specialised recordingapparatus, an appropriate environment and trainedmedical and scientifc personnel. Consequently, servicesare hospital based and usually only available inneuroscience centres or larger DGHs. Smaller DGHsmay provide outpatient EEG and nerve conductionstudies, but <strong>patients</strong> needing more specialisedinvestigation or inpatient studies will be treated intertiary centres, on a hub-and-spoke model. DGHs<strong>with</strong>out clinical neurophysiology services are at adisadvantage for managing <strong>patients</strong> <strong>with</strong> acuteneurological conditions and further plans to strengthenneurology support to these hospitals 2 should includeprovision for neurophysiology. Sources <strong>of</strong> referral areusually from secondary or tertiary care but somedepartments allow limited direct access from primarycare.3 Working <strong>with</strong> <strong>patients</strong>Patients referred for a neurophysiological opinion willusually be under the care <strong>of</strong> hospital consultants whowill explain the need for investigation. The results aresent to the referring <strong>physicians</strong>, but because <strong>of</strong> thecomplexity and technical nature <strong>of</strong> neurophysiologyreports, it is unusual for a copy being sent directly to thepatient. Where appropriate, the results may be discussed<strong>with</strong> the patient by a consultant clinicalneurophysiologist: HCSs are not usually in a position toprovide a tailored clinical opinion or discuss furtherC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 67


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>medical management. It is good practice to provideinformation to the <strong>patients</strong> in advance <strong>of</strong> anyinvestigation which explains the procedures as well aspossible risks and consent issues. The British Society forClinical Neurophysiology (BSCN) has producedrecommendations on patient information documentsthat, after local modifcation, are sent by mostdepartments <strong>with</strong> appointment letters. 3 Manyconditions investigated by clinical neurophysiology arelong-term illnesses and have excellent patient groupsand charities.4 Interspecialty and interdisciplinary liaison<strong>Consultant</strong> neurophysiologists are dependent on highlytrained and skilled scientifc support staff who typicallyperform all EEG and evoked potential studies and assist<strong>with</strong> nerve conduction recordings. Although clinicalreports are usually produced by medical personnel,scientifc staff are increasingly asked to provideprovisional reports, requiring close cooperation toensure limits <strong>of</strong> competence and standards aremaintained.There should be regular meetings and reviews betweenusers <strong>of</strong> neurophysiological services and the medicaland scientist staff who perform the studies. Althoughinformal discussion <strong>with</strong> referring clinicians to explainthe signifcance <strong>of</strong> results is a normal part <strong>of</strong> aconsultant’s work, more formal multidisciplinary teams(MDTs) may be required for EMG <strong>with</strong> neurologistsand pathologists, EEG <strong>with</strong> neurologists andpaediatricians and for sleep disorders <strong>with</strong> neurologistsand chest <strong>physicians</strong>. Large MDT meetings to includeneurologists, neurosurgeons, neuroradiologists andneuropsychologists are usual in centres undertakingcomplex surgical treatment <strong>of</strong> <strong>patients</strong> <strong>with</strong> intractableepilepsy. Liaison <strong>with</strong> many other <strong>physicians</strong> who refer<strong>patients</strong> to neurophysiology is via a written report,which must therefore be clear and capable <strong>of</strong> beingunderstood by non-specialists.The complexity and relative rarity <strong>of</strong> neurophysiologyinvestigation, and its dependence on equipment andsupport staff mean that there is limited opportunity forthe specialty to be delivered in the community.5 Delivering a high-quality serviceA high-quality neurophysiology service requiresappropriate facilities, equipment and trained staff.FacilitiesThe minimum requirements would include: a self-contained department in a quiet location a suffcient number <strong>of</strong> rooms large enough toaccommodate equipment, couches, <strong>patients</strong>,relatives and staff access for beds and disabled <strong>patients</strong> shielding from electrical interference ease <strong>of</strong> access for out<strong>patients</strong>, and proximity toneurological inpatient wards when video-telemetryis performed secretarial and staff <strong>of</strong>fces for the analysis <strong>of</strong> data,preparation <strong>of</strong> reports and clinical management <strong>of</strong>the service.EquipmentThe following equipment would be required: digital EEG recording apparatus <strong>with</strong> simultaneousvideo, preferably linked to a central server for dataanalysis and storage EMG and evoked potential recording systems more specialist equipment according to the services<strong>of</strong>fered (eg portable apparatus for operativemonitoring, video-telemetry, polysomnography) number and different types <strong>of</strong> machines to matchthe service demand regular maintenance contract to ensure safety andaccuracy.Education, training, mentoring and appraisal<strong>Consultant</strong>s in clinical neurophysiology will havetrained in the specialty following the curricularrequirements laid out by the Joint <strong>Royal</strong> <strong>College</strong>s <strong>of</strong>Physicians Training Board (JRCPTB) and regulated bythe General Medical Council (GMC). Occasionally,limited neurophysiological services are delivered byconsultants not trained in the specialty (although a fewneurologists have dual certifcation <strong>with</strong>neurophysiology), but the BSCN recommends that alldepartments <strong>of</strong>fering a comprehensive service aresupervised by a consultant in neurophysiology tomaintain standards. 4 The supervising consultant worksalongside the scientifc service manager to providedepartmental leadership and to ensure that local clinicalgovernance is in place, including in-house training andeducation, health and safety, appraisal and audit. TheBSCN, in conjunction <strong>with</strong> the Department <strong>of</strong> Healthand the Association <strong>of</strong> Neurophysiological Scientists(ANS), has developed quality standards for departments68 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Clinical neurophysiologyas part <strong>of</strong> the Improving Quality In Physiologicaldiagnostic Services (IQIPS) initiative hosted by the<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP). The UKAccreditation Service (UKAS) is expected to use thesestandards to accredit departments formally. Continuingeducation for consultants is through scientifc meetings<strong>of</strong> the BSCN. International clinical neurophysiologyconferences and a BSCN advanced course are held everythree to four years. <strong>Consultant</strong>s are expected to keep upto date by personal study, verifed at annual appraisal.The ANS supervises training for scientifc staff, anddelivers a certifcation process in addition to theuniversity education recently introduced underModernising Scientifc Careers. 5Specialty and national guidelines and auditsThe BSCN and the ANS have produced nationalguidelines and standards for the commonly performedneurophysiological procedure. 6 Audit has been locallyand regionally based, but the BSCN and ANS arepiloting national audit in 2011/12.6 Clinical work <strong>of</strong> consultantsThe <strong>working</strong> patterns <strong>of</strong> consultants in clinicalneurophysiology vary according to location andexpertise, but will typically include a mixture <strong>of</strong>specialist procedures and clinical reporting. Themajority <strong>of</strong> EMG and EEG work is for out<strong>patients</strong>although investigations are also required for acutely illin<strong>patients</strong>. <strong>Consultant</strong>s <strong>working</strong> in larger centres willusually provide some specialist investigations such asvideo-telemetry or intra-operative monitoring.Indications <strong>of</strong> appropriate numbers <strong>of</strong> investigationsper programmed activity (PA) are given in Table 1.These numbers should be reduced if there is a signifcanttraining component to the clinics/ reporting sessions orif the consultant is required to supervise otherpr<strong>of</strong>essionals such as specialty registrars (StRs) or HCSsat the same time as performing their own clinical work.The BSCN recommends that at least one hour in eachfour-hour EMG/NCS/EEG clinic should be allowed forclinical administration which includes responding toreferrals, the generation <strong>of</strong> written reports and othercommunications regarding the <strong>patients</strong>. Someneurophysiologists <strong>with</strong> neurological expertise mayhold clinical outpatient clinics, eg for epilepsy, but it isunusual for them to be involved in general internalmedicine. On-call commitments vary according to thesize <strong>of</strong> the department, <strong>with</strong> some centres being able toprovide a formal out-<strong>of</strong>-hours service whilst othershaving ad hoc arrangements in place.7 Opportunities for integrated careAs a diagnostic specialty, the majority <strong>of</strong>neurophysiology care is integrated <strong>with</strong> other specialties(including neurology and neurosurgery, paediatrics,rheumatology, orthopaedics and plastic surgery, generalmedicine, and ophthalmology) and <strong>with</strong>in clinicalpathways. MDT meetings are usual for complexdisorders including neurophysiology, such as thesurgical treatment <strong>of</strong> epilepsy.8 Workforce requirements for the specialtyThe RCP recommends that one consultant clinicalneurophysiologist is required to serve a population <strong>of</strong>approximately 300,000. The latest RCP census 7 records118 consultants in the UK, <strong>with</strong> 103 in England. Thisworkforce is not uniformly distributed around thecountry and the extremes are London, <strong>with</strong> oneconsultant to fewer than 300,000 <strong>patients</strong>, and theNorth West, South East Coast and East Midlands <strong>with</strong>one to (in excess <strong>of</strong>) 700,000 <strong>patients</strong>.The consultant workforce has consistently beeninsuffcient to meet demand for neurophysiologicalinvestigations despite consultant provision improvingin nearly all regions <strong>with</strong> total numbers doubling overthe last 10 years. Because <strong>of</strong> the small number <strong>of</strong>consultants and the need to work <strong>with</strong> others tomaintain continuing pr<strong>of</strong>essional development (CPD)and clinical standards, neurophysiology is concentratedin neuroscience centres to the detriment <strong>of</strong> DGHs andthe community. With the current workforce predictionsand numbers <strong>of</strong> trainees, the RCP recommendation isunlikely to be met in the near future.9 <strong>Consultant</strong> work programme/specimenjob plan<strong>Consultant</strong> work programmes will vary according tohospital size and the specialist services provided, andthe job plan will have to take into consideration localneeds. The key elements <strong>of</strong> a job plan are shown inTable1onthenextpage.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 69


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 <strong>Consultant</strong> work programme for clinical neurophysiologyActivity Workload (<strong>patients</strong> per PA) Programmed activities (PAs)Direct clinical carOutpatient EMG clinics 4–6 (depending on complexity) 2–5Inpatient EMG3–4 studies in the department,fewer if on wardUp to 1Supervision and reporting <strong>of</strong> HCS NCSclinics8–10 (4–5 per HCS clinic) 0–2Reporting routine EEG 10–15 (depending on complexity) 1–3Performing and reporting specialisedtests eg video-telemetry or visualelectrophysiologyIntra-operative procedures, eg evokedpotential monitoring, intracranialrecording/functional mapping1–5 0–3 (may be more inspecialist centres)0.5–1 0–4Multidisciplinary team meetings Up to 2Total number <strong>of</strong> direct clinical care PAs7.5 on averageSupporting pr<strong>of</strong>essional activities (SPAs)CPD/appraisal/revalidation 1.5Teaching/training 0–1Service development, clinicalgovernance, audit0–1Research 0–12.5 on averageOther NHS dutiesExternal dutieseg for deaneries, royal colleges,Department <strong>of</strong> HealthBy local agreementBy local agreement10 Key points for commissioners1 Clinical neurophysiology provides importantdiagnostic support for a number <strong>of</strong> specialties.2 These investigations are essential for themanagement <strong>of</strong> epilepsy and many peripheralnerve disorders, which are common and importantclinical conditions.3 Recent computerisation <strong>of</strong> recording apparatus hasensured that neurophysiology continues to have adiagnostic role.4 <strong>Consultant</strong> numbers are insuffcient for the servicedemand and consultants tend to be grouped inneuroscience centres.5 Neurophysiology is essential for managing someneurological emergencies and any move to increaseneurological provision in DGHs must includeneurophysiological support.6 Neurophysiology services are highly dependent ona scientifc workforce that must be continuallydeveloped. Departments should be supervised by aconsultant trained in clinical neurophysiology andhealthcare scientists should be appropriatelyqualifed for the investigations they undertake.7 Geographical distribution <strong>of</strong> neurophysiologyconsultants and trainees is skewed to London, <strong>with</strong>under-provision in some parts <strong>of</strong> the UK – adistribution that should be addressed.70 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Clinical neurophysiology8 Neurophysiological services depend on adequatefacilities, equipment and staff. Under-provision<strong>of</strong> any <strong>of</strong> these will result in a sub-standardservice.9 The nature <strong>of</strong> neurophysiology has resulted inconcentration <strong>of</strong> services in central departments.Moves to deliver the service in the community willrequireconsiderableinvestmentintechnologyandtrained manpower, along <strong>with</strong> education <strong>of</strong>referring <strong>physicians</strong>.10 In future, all service providers should achieveneurophysiological departmental standards and beaccredited by the appropriate bodies.References1 Macdonald BK, Coclerell OC, Sander WAS, Shorvon SD.The incidence and lifetime prevalence <strong>of</strong> neurologicaldisorders in a prospective community-based study in theUK. Brain 2000;123:665–76.2 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians and Association <strong>of</strong> BritishNeurologists. Local adult neurology services for the nextdecade. Report <strong>of</strong> a <strong>working</strong> party. London: RCP, ABN,2011.3 British Society for Clinical Neurophysiology. Preparation<strong>of</strong> patient information. www.bscn.org.uk/content.aspx?Group=gu ideline&Page=guidelines patientchecklist4 British Society for Clinical Neurophysiology. Statement<strong>of</strong> practice in clinical neurophysiology. www.bscn.org.uk/content.aspx?Group=guidelines&Page=guidelinespracticestatementapr20065 Department <strong>of</strong> Health. Modernising Scientifc Careers.www.dh.gov.uk/en/Aboutus/Chiefpr<strong>of</strong>essional<strong>of</strong>fcers/Chiefscientifc<strong>of</strong>fcer/DH 0866616 British Society for Clinical Neurophysiology. Guidelines.www.bscn.org.uk/content.aspx?Group=guidelines&Page=guid elines guidelines7 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> theUnited Kingdom. Census <strong>of</strong> consultant <strong>physicians</strong> andmedical registrars in the UK, 2010: data and commentary.London: RCP, 2011.Note to readers: This chapter was published in 2012 and the authors felt that it did not need updating for the revised 5th edition 2013.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 71


2 Specialties Clinical pharmacology and therapeuticsClinical pharmacology and therapeuticsDr Jeffrey Aronson Honorary consultant in clinical pharmacologyDr Stephen Jackson Pr<strong>of</strong>essor <strong>of</strong> clinical gerontologyPr<strong>of</strong>essor Munir Pirmohamed <strong>Consultant</strong> physician pharmacologyPr<strong>of</strong>essor James Ritter Honorary consultant physician1 Description <strong>of</strong> the specialtyClinical pharmacologists at consultant level may beemployed by universities (the majority), the NHS orpharmaceutical companies. Within industry, clinicalpharmacologists are involved in the development <strong>of</strong>new drugs and early clinical trials in <strong>patients</strong>.Clinical pharmacologists employed in the NHS anduniversities usually combine their specialty work <strong>with</strong>responsibilities as a general physician. This involves thesupervision <strong>of</strong> acute medical admissions, managingmedical in<strong>patients</strong> and running outpatient clinics.These individuals will normally have a clinicalsubspecialty interest (eg cardiovascular riskmanagement or toxicology) and will take a particularinterest in prescribing issues on behalf <strong>of</strong> theiremploying NHS body.The mission <strong>of</strong> the specialty is to improve the care <strong>of</strong><strong>patients</strong> by promoting the safe and effective use <strong>of</strong>medicines and to evaluate and introduce newtherapies. 1 Therefore, clinical pharmacologistswill <strong>of</strong>ten make wider contributions to the NHS clinicalservice. At a local level this will usually involve leading adrug and therapeutics committee, advising onnon-medical prescribing policy, developing andmaintaining a drug formulary, assessing new products,creating prescribing guidelines, reviewing adversemedication incidents and promoting evidence-basedtherapeutics.Some consultants may play a leading role in a‘medicines information service’ for local prescribers,<strong>with</strong> the support <strong>of</strong> a clinical pharmacist. At a nationallevel, consultants in clinical pharmacology andtherapeutics occupy many positions in key bodies suchas the National Institute for Health and Care Excellence(NICE), the Medicines and Healthcare productsRegulatory Agency (MHRA), the Commission onHuman Medicines (CHM), the joint formularycommittees that oversee publication <strong>of</strong> the BritishNational Formulary (BNF) and the BNF for children(BNFC), and adverse drug reaction monitoring(pharmacovigilance) schemes. The National PoisonsInformation Service (NPIS) is run almost exclusively byNHS clinical pharmacologists. They are also involved inresearch, both basic and clinical.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralSources <strong>of</strong> referral from primary, secondary andtertiary levelsClinical pharmacologists are active in promoting thesafe and effective use <strong>of</strong> medicines at all levels. At theprimary care level they develop and maintainformularies; at the secondary care level they lead drugand therapeutics committees and run drug informationservices; and at the tertiary level they are involved inorganisations such as the CHM’s adverse drug reactionmonitoring systems, the NPIS and the HealthTechnology Assessment (HTA) programme <strong>of</strong> theNational Institute for Health Research (NIHR).Locality-based and/or regional services;community models <strong>of</strong> careThe viability <strong>of</strong> local clinical networks is restricted bythe small number <strong>of</strong> consultants. However, clinicalpharmacologists <strong>of</strong>ten come together at a national levelin the setting <strong>of</strong> the adverse drug reactions monitoringsystem <strong>of</strong> the MHRA, NPIS and HTA.Clinical pharmacologists will usually have a closerelationship <strong>with</strong> one or more <strong>of</strong> the following: clinical pharmacy service medicines information unit clinical risk management committee primary care prescribing advisersC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 73


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> primary care trust (or equivalent) prescribingadvisers regional adverse drug reaction monitoring centre strategic health authority/health board.The work <strong>of</strong> clinical pharmacologists in promoting thesafe and effective use <strong>of</strong> medicines is complemented byclinical pharmacy services. Pharmacists <strong>of</strong>ten play animportant role in supporting the work <strong>of</strong> pr<strong>of</strong>essionalcommittees, providing information about medicines,preventing and reporting adverse medication incidents,and reporting adverse drug reactions. Some consultantsrequire an efficient laboratory service to support plasmadrug concentration monitoring and the assessment <strong>of</strong>poisoned <strong>patients</strong>. In some circumstances, the work <strong>of</strong> aclinical pharmacologist involves close collaboration<strong>with</strong> primary healthcare.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong>Involving <strong>patients</strong> in decisions about theirtreatmentClinical pharmacologists are not only practitioners <strong>of</strong>patient-centred care in their own clinical area but willalso, as part <strong>of</strong> their mission to deliver appropriate andrational therapeutics, promote improved understanding<strong>of</strong> drug therapy issues and support concordance <strong>with</strong>discussion <strong>of</strong> prescribing decisions between localprescribers and their <strong>patients</strong>, thus enhancingadherence. These objectives may be achieved throughthe education <strong>of</strong> doctors (at undergraduate andpostgraduate levels), <strong>with</strong> emphasis on patientinvolvement in therapeutic choices, informed consentand promotion <strong>of</strong> self care, and through the education<strong>of</strong> <strong>patients</strong> by disseminating relevant information.Clinical pharmacologists also endeavour to improve theefficacy and safety <strong>of</strong> medicines through the promotion<strong>of</strong> evidence-based medicine and the development <strong>of</strong>guidelines and shared-care protocols. They will,whenever possible, liaise <strong>with</strong> patient groups and layrepresentatives when developing prescribing policies.4 Interspecialty and interdisciplinary liaisonClinical pharmacologists <strong>of</strong>ten have importantrelationships <strong>with</strong> other specialist groups and primarycare colleagues. They usually have an interest in medicalsubspecialties, particularly cardiovascular, respiratory,and metabolic medicine, in which liaison <strong>with</strong> otherclinical groupings, such as cardiology and strokemedicine, is important. It is likely that they will work aspart <strong>of</strong> a multidisciplinary team (MDT) involvingpharmacists and nurses in the pursuit <strong>of</strong> medicinesmanagement and when carrying out clinical trials.5 Delivering a high-quality serviceA high-quality service includes: a well-organised and efficiently run drug andtherapeutics committee drawing on relevant localexpertise an agreed local formulary development and regular review <strong>of</strong> local prescribingpolicies that support safe, evidence-based andcost-effective prescribing regular audit <strong>of</strong> prescribing quality contributions to clinical risk management throughregular review <strong>of</strong> adverse medication incidents(adverse drug reactions and medication errors) encouraging adverse drug reaction reporting bylocal prescribers regular high-quality education in appropriate andrational prescribing for undergraduates andpostgraduates early review <strong>of</strong> and advice concerning poisoned<strong>patients</strong>.Maintaining and improving the quality <strong>of</strong> careQuality and standards in clinical pharmacology arelargely expressed by local prescribers in the primary andsecondary healthcare sectors in relation to the approachto appropriate and rational use <strong>of</strong> medicines, not byclinical pharmacologists alone. The measurement <strong>of</strong>quality and standards in relation to the provision <strong>of</strong> aclinical pharmacology service is therefore problematic.However, potential means to ensure and measurequality do exist, through adherence to widely applicablenational guidelines, dissemination <strong>of</strong> relevantprescribing information, and implementation <strong>of</strong>cost-effective prescribing patterns and audit <strong>of</strong>prescribing practices.This work encompasses duties in clinical governance,pr<strong>of</strong>essional self-regulation; continuing pr<strong>of</strong>essionaldevelopment (CPD); and the mentoring, education andtraining <strong>of</strong> others. For many consultants at varioustimes in their careers it will include research; serving inmanagement; and providing specialist advice at local,regional and national levels.74 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Clinical pharmacology and therapeuticsAlthough the supervision and management <strong>of</strong> generalmedical <strong>patients</strong> is a major direct contribution to theNHS, most consultants in clinical pharmacology andtherapeutics take on other roles that contributeindirectly to achieving local NHS service objectivesand standards. These activities usually focus on themanagement <strong>of</strong> medicines in primary and secondarycare, eg: leading or playing an important role in the activities<strong>of</strong> drug and therapeutics committees and overseeingthe use <strong>of</strong> drugs in both hospitals and primary care managing a local drug formulary, which may bejointly agreed <strong>with</strong> local GPs editing and facilitating the production <strong>of</strong> localprescribing guidelines for common medicalproblems taking a lead role in reporting adverse drug reactionsand reviewing local medication errors undertaking HTA, which might involve reviewingnew and established drugs for clinical andcost-effectiveness purposes auditing and reviewing patterns <strong>of</strong> local drug use,<strong>with</strong> the aim <strong>of</strong> maximising effective and safe use <strong>of</strong>medicines in the NHS.All <strong>of</strong> these activities make an important contributionto achieving local objectives in clinical effectiveness,clinical risk management and clinical governance.Clinical pharmacologists are likely to play a major rolein auditing and investigating local drug-relatedincidents.Some consultants provide a drug information service,<strong>of</strong>ten <strong>with</strong> the support <strong>of</strong> a clinical pharmacist. Thismay include a plasma drug concentration monitoringservice, advising on the management and prevention<strong>of</strong> medication errors, and an advice service on drugoverdoses and the management <strong>of</strong> adverse drugreactions. Some consultants have a specialist interest inforensic pharmacology and provide expert advice incoroners’, criminal and civil cases. There should beadequate provision for all <strong>of</strong> these important publichealth and additional service commitments <strong>with</strong>inajobplan.6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialtyClinical pharmacologists have varied <strong>working</strong> patterns,but most NHS and academic consultants are accreditedin clinical pharmacology and therapeutics (CPT), <strong>with</strong>general internal medicine (GIM) as their secondspecialty. However, the skills <strong>of</strong> clinical pharmacologyand therapeutics are generic and are fully applicable toother medical specialties. A few consultants also practisein specialties such as geriatric medicine, cardiology,paediatrics, oncology, respiratory medicine orrheumatology, and it is likely that the number <strong>of</strong> suchconsultants will increase as more varied trainingschemes are established.Inpatient workActivities will normally be devoted to supervising themanagement <strong>of</strong> acute medical <strong>patients</strong> and the specialistwork <strong>of</strong> the individual consultant. This work typicallyrequires two ward rounds per week at fixed times. 2 Thenumber <strong>of</strong> in<strong>patients</strong> for which the consultant team isresponsible should ideally not exceed 20 <strong>patients</strong>. Part<strong>of</strong> this time will be dedicated to inpatient referrals for<strong>patients</strong> <strong>with</strong> pharmacological or toxicologicalproblems. <strong>Consultant</strong>s expect to work in an adequatelystaffed ward, <strong>with</strong> the appropriate facilities and ancillaryservices to care for a typical casemix <strong>of</strong> general medical<strong>patients</strong>. They should have the support <strong>of</strong> at least onejunior doctor who has completed general pr<strong>of</strong>essionaltraining.Outpatient workTime will be allocated for seeing new patient referrals,including emergency referrals and follow-up afterdischarge from accident and emergency or a hospitalward. <strong>Consultant</strong>s normally provide this service <strong>with</strong>the support <strong>of</strong> junior staff and must allow time for theirsupervision. It is reasonable to expect that theassessment <strong>of</strong> a new patient will take approximately 30minutes and follow-up <strong>patients</strong> approximately15 minutes. Trainees require more time and should notwork in isolation. A typical clinic might include 4–6new <strong>patients</strong> and 10–15 follow-up <strong>patients</strong>. Thesesessions should include time for dictating clinic lettersand administrative matters relating to the out<strong>patients</strong>ervice. Some clinical pharmacologists also providespecialist clinics, eg in cardiovascular risk management,asthma, or epilepsy. Patients are sometimes referred<strong>with</strong> specific therapeutic, toxicological or otherdrug-related problems.Specialist investigative or therapeutic proceduresClinical pharmacologists will not normally undertakespecialist procedures other than those that arise fromother specialty activities.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 75


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Specialist on callClinical pharmacologists have traditionally taken aparticularly active role as general non-organ-based<strong>physicians</strong> in the on-call rota for supervision <strong>of</strong>receiving and triaging acute emergency admissions.These duties should be undertaken <strong>with</strong> the support <strong>of</strong>an appropriate number <strong>of</strong> junior doctors, including aspecialty registrar (StR). Acute general medicaladmissions should ideally be admitted to a medicaladmissions unit <strong>with</strong> appropriate staffing and access toemergency investigations. 3 The on-call rota should notbe more onerous than one in five. Each period <strong>of</strong> acuteadmitting must include a post-take ward round <strong>with</strong> thejunior staff who were involved in the admission process.In some services, two ward rounds may be required in a24-hour period. <strong>Consultant</strong>s who are responsible forthe review <strong>of</strong> poisoned <strong>patients</strong> have more frequentpost-receiving ward rounds.A common on-call commitment <strong>of</strong> a clinicalpharmacology service is the provision <strong>of</strong> emergencyadvice about the management <strong>of</strong> poisoned <strong>patients</strong>.This activity will usually be supported by a poisonsinformation service, and clinical pharmacologists may<strong>of</strong>fer regional advice. Some academic specialists mayhave out-<strong>of</strong>-hours commitments to subjects involved inclinical trials.Clinically related administrationClinical pharmacologists will have administrative dutiesin keeping <strong>with</strong> their clinical workload. They may alsobe called upon to write specialist reports related tomedication issues.Academic medicineThe large majority <strong>of</strong> consultants in clinicalpharmacology and therapeutics hold academic posts,which adds to the particularly diverse contributions thatthe specialty makes to the delivery <strong>of</strong> healthcare.<strong>Consultant</strong>s in major teaching centres also play a keyrole in the design and delivery <strong>of</strong> teaching intherapeutics to medical students. 4 For new medicalgraduates, prescribing drugs is a major activity and onethat is associated <strong>with</strong> significant clinical risk. For thesereasons therapeutics remains an important theme<strong>with</strong>in any medical curriculum and requiresappropriate support from clinical teachers. Clinicalpharmacologists are also involved in the delivery <strong>of</strong>postgraduate training in therapeutics to other healthpr<strong>of</strong>essionals in the NHS, including GPs, nurses andpharmacists.Research is a fundamental part <strong>of</strong> the work <strong>of</strong> manyclinical pharmacologists. It involves clinical research in<strong>patients</strong> and healthy volunteers, and some individualslead teams <strong>of</strong> laboratory-based researchers.Drug-related research activities make an importantcontribution to local and national NHS research anddevelopment strategies, providing important long-termbenefits for patient care. The success <strong>of</strong> these activitieswill depend on the availability <strong>of</strong> suitable clinical andlaboratory areas, recognition <strong>of</strong> the need for protectedresearch sessions, and the support <strong>of</strong> appropriatelytrained clinical and technical staff. Clinicalpharmacologists <strong>of</strong>ten have an important role on (orchair) local and multicentre research ethics committees,because <strong>of</strong> their expertise in drug-related research.7 Opportunities for integrated careClinical pharmacologists frequently work <strong>with</strong> scientistsand technical staff in order to provide therapeutic drugmonitoring services. Close <strong>working</strong> <strong>with</strong> pharmacists isalso undertaken, running formulary and drug andtherapeutics committees. Similarly, subspecialty clinicssuch as hypertension and vascular risk clinics may beprovided, <strong>working</strong> <strong>with</strong> pharmacists and nurses whomay also prescribe. Although communication <strong>with</strong>primary care concerning patient management isessential, clinical pharmacologists have not traditionallyprovided integrated services across primary care, butthe potential is there, particularly <strong>with</strong> regard tomedication review.8 Workforce requirements for the specialtyThe 2009 consultant census by the Federation <strong>of</strong> <strong>Royal</strong><strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK reported that therewere 51 whole-time equivalent (WTE) consultants inclinical pharmacology and therapeutics in England andWales, equivalent to one per 1.027 million population. 5The following calculation reflects the number <strong>of</strong>consultants needed to ensure that there are sufficientclinical pharmacologists to contribute to nationalbodies and to provide a high-quality local nationalservice, <strong>with</strong> particular emphasis on medicinesmanagement, toxicology, and academic activities suchas teaching and research. The workforce alsocontributes to the care <strong>of</strong> unselected acute generalmedical admissions. The calculation takes into accountseveral important trends; drugs account for anincreasing proportion <strong>of</strong> NHS expenditure (currently76 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Clinical pharmacology and therapeuticsabove 15% <strong>of</strong> the total) and there are pressures toprescribe newer, more expensive medicines. There is a requirement to contain costs by adoptingagreed formularies and making rigorous assessments<strong>of</strong> the clinical and cost effectiveness <strong>of</strong> new drugs. There has been a significant expansion in medicalstudent numbers to around 6,000 annually, whichhas been maintained. Acute general medical admissions are increasingannually. The increasing burden on <strong>physicians</strong> running aspecialty service (eg gastroenterology andcardiology) is creating difficulties in providing acutemedical cover. Junior doctors’ hours <strong>of</strong> work have decreased andthis continues to have an impact.Clinical pharmacology is one <strong>of</strong> the few specialtieswhose numbers are currently decreasing – numbers inEngland and Wales fell by three consultants in the threeyears to 2009. Sufficient consultants are required todeliver academic programmes, including teaching.There is a strong case to be made for having one WTEclinical pharmacologist in every large district generalhospital (DGH) for acute medicine and to address thespecialty needs <strong>of</strong> trusts and local primary care trusts.Using a previously developed model, the workforcerequirement for consultants in clinical pharmacologyand therapeutics is approximately 440 WTE. Thisnumber <strong>of</strong> consultants is based on providing: one WTE consultant per DGH serving a population<strong>of</strong> 250,000 one WTE consultant per 180 medical students intraining.In the present climate, this expansion is unrealistic andit is felt that expansion <strong>of</strong> a minimum <strong>of</strong> 10% perannum over the next decade is realistic. This wouldincrease numbers to almost 150.Following the successful joint initiative<strong>of</strong> the NHS Executive and the Association <strong>of</strong> the BritishPharmaceutical Industry (ABPI), the number <strong>of</strong> traineesin clinical pharmacology increased during the 1990s, butthis scheme has ended. Recent initiatives by the WellcomeTrust, the Medical Research Council and the NIHRwill increase the numbers <strong>of</strong> research-trained clinicalpharmacologists, but more NHS posts are required.9 <strong>Consultant</strong> work programme/specimenjob planReflecting acute medicine commitment oracademic appointment as appropriateTables 1 and 2 summarise the range <strong>of</strong> activitiesundertaken by consultant <strong>physicians</strong> in clinicalpharmacology and therapeutics <strong>with</strong> responsibilities inGIM, the recommended workload and the allocation <strong>of</strong>programmed activities (PAs) (each PA is considered tobe a period <strong>of</strong> four hours). The job plan is based on acommitment <strong>of</strong> 10 PAs per week, although the typical<strong>working</strong> patterns <strong>of</strong> clinical pharmacologists involveextra PAs. Suggested work programmes have beenprovided for a consultant <strong>working</strong> in a universityteaching hospital (Table 1) and one in a DGH (Table 2).Academic clinical pharmacologists will normally hold afull-time university contract (the full-time salary beingpaid by the university) and an honorary (unpaid) NHScontract. The honorary contract will normally includenotmorethanfiveNHSPAs,<strong>of</strong>whichnomorethan3.5 PAs will be devoted to direct clinical care activities(as defined in the 2003 consultant contract). The award<strong>of</strong> these concurrent contracts recognises thecontribution that academic consultants make, bothdirectly and indirectly (medicines management) to theNHS clinical service. This arrangement also recognisesthat the activities carried out on behalf <strong>of</strong> the NHS havevalue for teaching and research. The job plan <strong>of</strong> anacademic clinical pharmacologist will be made byagreement between the consultant, the dean and themedical director <strong>of</strong> the NHS body (or their nominatedrepresentatives) and will take full account <strong>of</strong> theprinciples set out in the Follett Report 2001 concerningthe relationship between academic and clinicalworkload. 6 The academic contract will includeresponsibilities for research, undergraduate teachingand administration relating to these and other NHSduties. In some cases it will be the university departmentas a whole that makes a commitment to provide a fixednumber <strong>of</strong> PAs to the NHS service, allowing for moreflexible participation <strong>of</strong> the individual academicconsultants in clinical duties.10 Key points for commissioners1 Clinical pharmacology and therapeutics is a diversespecialty, <strong>with</strong> consultants <strong>of</strong>ten undertaking verydifferent clinical activities.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 77


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 <strong>Consultant</strong> work programme/specimen job plan for an academic clinical pharmacologist <strong>working</strong> in auniversity teaching hospital, based on 10 PAsActivity Workload Programmed activities (PAs)Direct clinical careEmergency duties arising from acute receiving(24 hours)Inpatient (ward rounds, referrals, MDTmeetings)10–15 <strong>patients</strong> 0–110–15 <strong>patients</strong> 0–1Outpatient clinics 5–10 <strong>patients</strong> 0–1Administration directly related to patient care(eg referrals, notes, complaints, correspondence<strong>with</strong> other practitioners)Public health duties, eg medicinesmanagement: running a drug and therapeuticscommittee, managing a formulary, developingprescribing policies, health technologyassessment, drug information services0.5–10–2Supporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong>healthcareOther NHS responsibilitiesExternal dutieseg CPD, postgraduate teaching and training,management <strong>of</strong> doctors in training, audit, jobplanning, appraisal, revalidation, contributionto service management and planning, clinicalgovernance activitieseg Caldicott guardian, clinical audit lead,clinical governance lead, undergraduate andpostgraduate dean, clinical tutor, regionaleducation adviser, medical managementresponsibilitieseg work for NHS bodies (eg advisorycommittees), work for other external bodies (egMHRA, CHM, NICE, royal colleges, GeneralMedical Council (GMC), Postgraduate MedicalEducation and Training Board (PMETB), BritishMedical Association (BMA), BNF and BNFC),NHS disciplinary procedures, NHS appealsprocedures, advisory appointments committees1.5 on averageLocal agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trustAcademic duties Teaching undergraduates 1–2Research 2–4University administration 1Note: PA = programmed activities equivalent to 4 hours each.2 As almost all are trained in GIM, the potentialcombination <strong>with</strong> acute medicine for newappointments is attractive.3 <strong>Consultant</strong> clinical pharmacologists’ contribution tothe acute medical take means that specialty traineeswill contribute to the medical registrar rota.4 Management <strong>of</strong> drug formularies and therefore drugexpenditure is an important contribution to localhealth economies, which clinical pharmacologistsare trained to undertake.5 Clinical pharmacologists are well placed to supportthe infrastructure needs <strong>of</strong> NHS trusts to manage78 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Clinical pharmacology and therapeuticsTable 2 <strong>Consultant</strong> work programme/specimen job plan for a NHS consultant clinical pharmacologist <strong>working</strong>in a DGH, based on 10 PAsActivity Workload Programmed activities (PAs)Direct clinical careEmergency duties arising from acute receiving(24 hours) including dealing <strong>with</strong> poisoned<strong>patients</strong>Inpatient (ward rounds, referrals, MDTmeetings)20–30 <strong>patients</strong> 1–220–25 <strong>patients</strong> 1–2Outpatient clinics 15–20 <strong>patients</strong> 1–2Administration directly related to patient care(eg referrals, notes, complaints,correspondence <strong>with</strong> other practitioners)Public health duties, eg medicinesmanagement: running a drug and therapeuticscommittee, managing a formulary, developingprescribing policies, health technologyassessment, drug information services1–21–2Supporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong>healthcareOther NHS responsibilitiesExternal dutieseg CPD, teaching and training, management<strong>of</strong> doctors in training, audit, job planning,appraisal, revalidation, research, contributionto service management and planning, clinicalgovernance activitieseg Caldicott guardians, clinical audit leads,clinical governance leads, undergraduate andpostgraduate deans, clinical tutors, regionaleducation advisers, medical managementresponsibilitieseg work for national NHS bodies, work for otherexternal bodies (eg MHRA, CHM, NICE, royalcolleges, GMC, PMETB, BMA), NHS disciplinaryprocedures, NHS appeals procedures, advisoryappointments committees2.5Local agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trustnon-medical prescribing both in primary andsecondary care. This area <strong>of</strong> practice is likely tocontinue to grow.6 The subspecialty interest <strong>of</strong> hypertension andvascular risk management is widely practised byclinical pharmacologists and is going to becomeeven more important <strong>with</strong> the rise in prevalence<strong>of</strong> obesity and metabolic syndrome.7 Those clinical pharmacologists <strong>with</strong> othersubspecialty interests, such as epilepsy, asthma, orclinicaltoxicology,willalsobeabletocontributetoNHS trusts’ clinical workload.8 As all NHS trusts are required to have a research anddevelopment portfolio and to undertake recruitmentto portfolio studies, clinical pharmacologists, whoarealltrainedinresearch,cancontributetothisactivity and facilitate other clinicians to take part.References1 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Clinical pharmacology andtherapeutics in a changing world.Report<strong>of</strong>a<strong>working</strong>party. London: RCP, 1999.2 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Governance in acute generalmedicine. Recommendations from the Committee onC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 79


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>General (Internal) Medicine <strong>of</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong>Physicians. London: RCP, 2000.3 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK.Acute medicine: the physician’s role. Proposals for thefuture. A <strong>working</strong> party report <strong>of</strong> the Federation <strong>of</strong>Medical <strong>Royal</strong> <strong>College</strong>s. London: RCP, 2000.4 Maxwell SRJ, Walley T. Teaching prescribingtherapeutics. Br J Clin Pharmacol 2003;55:496–503.5 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK.Census <strong>of</strong> consultant <strong>physicians</strong> and medical registrars inthe UK, 2009: data and commentary. London: RCP, 2010.6 Follett B, Paulson-Ellis M. A review <strong>of</strong> appraisal,disciplinary and reporting arrangements for senior NHSand university staff <strong>with</strong> academic and clinical duties.Areport to the Secretary <strong>of</strong> State for Education and Skills.London: DfES, 2001.80 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties DermatologyDermatologyNick J Levell MD FRCP MBA <strong>Consultant</strong> dermatologistStephen K Jones MD FRCP <strong>Consultant</strong> dermatologistChristopher B Bunker MD FRCP <strong>Consultant</strong> dermatologist1 Description <strong>of</strong> the specialtyDermatologists are the only experienced, trained andaccredited specialists in the diagnosis and management<strong>of</strong> diseases <strong>of</strong> the skin, hair and nails in adults andchildren. There are no others who can provide care <strong>of</strong>equal quality to that <strong>of</strong> dermatologists; however, thereare only 650 consultant dermatologists in the UK, many<strong>of</strong> whom work part time. Over 2,000 skin disorders arerecognised, so accurate diagnosis is fundamental tosuccessful management. Each year 54% <strong>of</strong> thepopulation are affected by skin disease, and 23–33% atany one time have disease that would benefit frommedical care. 1,2 Approximately 4,000 deaths occur inthe UK annually due to skin disease, most <strong>of</strong>ten frommalignant melanoma. 1 Skin diseases represent 34% <strong>of</strong>disease in children, 2 <strong>with</strong> atopic eczema affecting 20%<strong>of</strong> infants. Dermatologists organise and deliver skincancer services. Others subspecialise in complexmedical dermatology, surgery including Mohs’micrographic surgery, allergy, paediatrics, genitaldisorders, photodermatology, psychodermatology anddermatopathology.Skin cancer is the most common cancer and the secondmost common cancer causing death in young adults.Basal cell carcinoma (BCC) numbers equal all othermalignancies combined, and increased by 81% between1999 and 2010. 3 Reported melanoma incidenceincreased by over 400% over 35 years. 4 Hand eczema isone <strong>of</strong> the most common reasons for disablementbenefit in the UK. Inflammatory skin diseases aredisabling, disfiguring and distressing, and reducequality <strong>of</strong> life. Expectations <strong>of</strong> the public have changedand will continue to change in particular <strong>with</strong>regard to skin disease appearance which can be <strong>of</strong> greatimportance, causing disability and loss <strong>of</strong> function. 1The pr<strong>of</strong>essional society for dermatologists is the BritishAssociation <strong>of</strong> Dermatologists (BAD)(www.bad.org.uk), a charity funded by the activity <strong>of</strong>British dermatologists. The objects are to furtherknowledge, practice, teaching and research <strong>of</strong>dermatology and to advise other interested parties(including healthcare providers and politicians) indermatology. Dermatologists not only provide care butare active in improving systems for healthcare.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralEach year 24% <strong>of</strong> the population see their GPs for skindisease and 882,000 5 were referred to dermatologists inEngland in 2009–10 <strong>with</strong> 2.74 million 5 consultations.This reflects an increased prevalence <strong>of</strong> atopic eczemaand skin cancer, availability <strong>of</strong> more effective treatmentsand patient demand.<strong>Consultant</strong> dermatologists are the most efficientproviders <strong>of</strong> skin care, leading interdisciplinary teamsincluding specialty doctors and associate specialist(SAS) doctors, GPs and nurses <strong>working</strong> in secondaryand integrated intermediate care. Governmentinitiatives have experimented <strong>with</strong> dermatology servicedelivery and evidence consistently shows that careshould always be delivered by individuals <strong>with</strong> the rightskills, in the right setting, the first time. Triage by anexpert familiar <strong>with</strong> the full range <strong>of</strong> services ensuresthat <strong>patients</strong> are directed to high-quality, cost-efficientcare from the outset. Misuse <strong>of</strong> non-accredited doctorsas long-term locum dermatologists should be decried.Primary care servicesThere are 13 million primary care consultations for skindiseases each year. 1 Outcomes could be enhanced byimproving undergraduate dermatology teaching andlearning, which averages approximately 6 days only.Most GP training schemes have no dermatologyattachment. New Department <strong>of</strong> Health (DH)guidelines allow limited skin surgery to be undertakenunder local enhanced (LES) and direct enhanced (DES)GP services, provided that correct governancearrangements are followed. 6Community specialist nurses can provide supportfor education and self-management <strong>of</strong> chronicC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 81


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>inflammatory skin diseases such as psoriasis, eczema investigation <strong>of</strong> photodermatoses, which affect 18%and acne. They can enhance care but there is no<strong>of</strong> the population reducing quality <strong>of</strong> life,evidence that they reduce secondary carepsychological welfare and employabilityreferrals. management <strong>of</strong> skin problems in hospital <strong>patients</strong><strong>with</strong> other illnesses, thereby reducing length <strong>of</strong> stayIntermediate services(LOS)GPs <strong>with</strong> a special interest (GPwSIs) in dermatology can skin cancer screening for organ transplantprovide effective intermediate care for individuals <strong>with</strong> recipientschronic mild/moderate inflammatory diseases, skin genital skin diseasesinfections, sun damage and certain skin cancers as part management <strong>of</strong> genodermatoses<strong>of</strong> an integrated consultant dermatologist-led team. 6 cutaneous infections, tropical diseases and HIV skinThere is no good evidence that these services reduce diseasessecondary care referrals or save money; they may cellulitis day-case services producing substantial‘de-skill’ GP colleagues. 7,8 There are detailed DH safety, NHS savingsgovernance and training guidelines for the accreditation teaching, training and assessment <strong>of</strong> medical<strong>of</strong> GPwSIs, which some primary care trusts (PCTs) students, GPs, trainee dermatologists and otherignore, risking patient safety.healthcare pr<strong>of</strong>essionals collection and analysis <strong>of</strong> clinical data, clinical auditSecondary care servicesand compliance <strong>with</strong> clinical governanceSecondary care dermatology services receive 882,000 requirementsreferrals each year in England (approximately 16 per clinical research including therapeutic trials1,000 population). 9 Up to 50% <strong>of</strong> referrals relate to skin contributions to the wider NHS including NICE,cancer. Specialist services include:Care Quality Commission, the RCP and BAD(producing guidelines, patient information and skin cancer clinics – dermatologists screen over 90% outcome measures).<strong>of</strong> skin cancer referrals, treat approximately 75% andreassure the remainder; the National Institute for Hospital-based services require at least one whole-timeHealth and Care Excellence (NICE) recommends equivalent consultant dermatologist per 62,500that high-risk BCCs (the majority <strong>of</strong> cases) are population (see section 8). SAS doctors form an integraltreated in secondary carepart <strong>of</strong> the hospital team. Departments require the facilities for dermatological surgery, cancersupport <strong>of</strong> pharmacists and trained specialistmultidisciplinary teams (MDTs) and data collection dermatology nurses who meet competency standardscompliant <strong>with</strong> NICE guidanceset by their pr<strong>of</strong>essional body, the British Dermatology medical dermatology for complex problems, <strong>of</strong>ten in Nursing Group (www.bdng.org.uk).TrainedMDT clinics <strong>with</strong> other specialties such asdermatology nurses can:rheumatology inpatient care <strong>of</strong> sick <strong>patients</strong> <strong>with</strong> severe skin treat <strong>patients</strong> in day-care units and on wards,diseases or skin failure, sometimes requiringprovide and supervise phototherapy, assist <strong>with</strong>intensive carepatch testing under consultant supervision, perform phototherapy (see BAD and Britishsurgical procedures, and care for wounds and ulcersPhotodermatology Group <strong>working</strong> party report), 10 provide patient information, demonstrate and applyiontophoresis, wound care and other day treatments treatments, dress wounds, remove sutures and day-case units for infusion <strong>of</strong> disease-modifying review follow-upsdrugs assist in operating theatres and advise <strong>patients</strong> paediatric dermatology services including laserundergoing surgerysurgery (see BAD and British Society for Paediatric advise and train pr<strong>of</strong>essional colleagues caring forDermatology <strong>working</strong> party report) 11<strong>patients</strong> <strong>with</strong> skin diseases in the hospital/ investigation <strong>of</strong> cutaneous allergy and occupational communityskin disease by patch and prick testing (see BAD and <strong>with</strong> paediatric training, run hospital/outreachBritish Society for Cutaneous Allergy <strong>working</strong> party services for children <strong>with</strong> chronic skin disease.report) 12 Establish and run community clinics82 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Dermatology run monitoring clinics for isotretinoin andbiologic/systemic treatments for inflammatory skindiseases.Tertiary care servicesThe UK has many national and international experts indermatology who provide services for complex cases.As <strong>of</strong> January 2011, national commissioned groupservices in England exist for: xeroderma pigmentosum,epidermolysis bullosa, Ehlers–Danlos syndrome,neur<strong>of</strong>ibromatosis types 1 and 2, Fabry disease andcryopyrin diseases. The National Commissioning BoardDermatology Clinical Reference Group is developing, in2013, nationally commissioned networks <strong>of</strong> specialisedservices in over 20 areas <strong>of</strong> dermatology, which may becommissioned from April 2013 onwards. Proposals forthis service include virtual MDTs <strong>with</strong> referralsdelivered through a portal hosted by the BAD.Psychological servicesPeople <strong>with</strong> skin disorders <strong>of</strong>ten benefit frompsychological intervention, but services are <strong>of</strong>tenlimited by NHS financial restraints. The NICEguidelines for skin cancer care require psychologicalservices to be available for those <strong>with</strong> skin cancer.Community careCommunity pharmacists can reinforceself-care/self-help messages at the point <strong>of</strong> dispensingfor <strong>patients</strong>. People spent £413 million (18% <strong>of</strong>over-the-counter (OTC) sales) on skin treatments in theUK in 2007. 1Camouflage services may be an integral part <strong>of</strong> care.Complementary servicesAlternative therapies lack evidence <strong>of</strong> efficacy and safetyand some (eg eastern herbal treatments) may containpotent corticosteroids or liver toxins.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareEnsuring that the patient is at the centre <strong>of</strong> carePatient involvement and choiceInvolving <strong>patients</strong> in choice and decision-making abouttheir care has been improved by increasing consultationtimes <strong>with</strong> doctors and nurses and by providing qualityinformation such as BAD patient information leaflets(PILS) (available at www.bad.org.uk).Patient choice would be enhanced were information for<strong>patients</strong> available, at the point <strong>of</strong> choice, about thequalifications, experience and accreditation <strong>of</strong> doctorsproviding services.Patient support groups and access to informationThe BAD recognises and supports 55 patient supportgroups (PSGs), providing links to their websites fromwww.bad.org.uk, where over 130 PILS on over 120conditions are available.Education and promoting self-care for acute andchronic skin diseasesInformation provided by PSGs is invaluable. The BADprovides ongoing support, including financial grants, tothe PSGs.Role <strong>of</strong> the expert patientThe Dermatology Councils for England, Scotland andWales represent multiple stakeholders including thePSGs. Patient and public involvement groups (PPIs)are active in many dermatology departments.4 Interspecialty and interdisciplinary liaisonDermatology care is carried out most efficiently in theUK using a hospital-based team led by a consultantdermatologist, <strong>with</strong> SAS doctors, GPs and nurses insecondary and integrated intermediate care.Multidisciplinary teams in skin cancer clinics involvedermatologists, surgeons, histopathologists,oncologists, radiotherapists, nurses, and psychiatristsand psychologists (see BAD and PsychodermatologyUK <strong>working</strong> party report on psycho-dermatology). 13Combined clinics between dermatologists and hospitalspecialists exist for complex problems, eg involvingrheumatology, plastic surgery, HIV, genital/oraldiseases, psychiatry, paediatrics, genetics, stomas, eyes,vascular surgery and allergy.5 Delivering a high-quality dermatologyserviceWhat is a high-quality service?A dermatology service should provide patient-centredcare focusing on outcomes that meet national standards.To achieve this, all staff must be correctly trained andaccredited and the local service structure should provideC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 83


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>facilities that enable safe and effective investigation andtreatment. A multi-stakeholder document, theproduction <strong>of</strong> which was supported by the DH Qualitystandards for dermatology, provides commissioners <strong>with</strong>guidance in commissioning high-quality dermatologyservices. 14 A high-quality service should follow andaudit compliance <strong>with</strong> national guidelines provided byNICE and the BAD, and should participate inBAD-facilitated and -hosted national audits.Staffing<strong>Consultant</strong> dermatologists should be on the specialistregister <strong>of</strong> the General Medical Council (GMC). Theyshould not work alone and must have appropriatesupport staff including specialist dermatology nursesand trained secretarial staff.Local facilities needed for dermatology <strong>patients</strong> 15The following local facilities are needed: dedicated outpatient units <strong>with</strong> rooms for patienteducation, breaking bad news and counselling areas for contact allergy testing <strong>with</strong> storage areas forallergens meeting national published standards surgical facilities meeting national standards forspace, cleanliness and equipment, <strong>with</strong> storage forliquid nitrogen laser-safe areas where required facilities for Mohs’ micrographic surgery whererequired, meeting national standards day-care centres staffed by dedicated dermatologynurses phototherapy units for adults and children staffed bytrained dermatology nurses who can also provideskin care (unlike physiotherapists), meeting nationalstandards for equipment and safety. Medicalphysicists should monitor ultraviolet (UV) output.A named consultant dermatologist should beresponsible for the service hospital beds staffed by trained specialistdermatology nurses <strong>with</strong> 24-hour medical care.Dermatology <strong>patients</strong> require a specialiseddermatology nurse to apply treatments and provideeducation, <strong>with</strong> adequate bathing and treatmentrooms. In<strong>patients</strong> should be geographically close tooutpatient units for maximal efficiency laboratory support including chemical pathology,haematology, radiology, microbiology, mycology,histopathology and immunopathology information technology (IT) hardware and s<strong>of</strong>twarethat is robust, modern, reliable, fast, in the rightplace and immediately available medical photography services (eg for mole mappingand monitoring) comprehensive pharmacy services appropriate accommodation for paediatricdermatology clinics and inpatient care.Maintaining and improving quality <strong>of</strong> careDermatologists lead the team delivering clinicalservices, driving service developments/innovations toimprove patient outcomes.Education and trainingEducation and training <strong>of</strong> medical students, specialtyregistrars (StRs), GPs and nurses improve care for<strong>patients</strong> <strong>with</strong> skin disease. Twenty per cent <strong>of</strong> GPconsultations relate to skin disease but only 20% <strong>of</strong> GPtraining schemes include dermatology. Medicalstudents, on average, receive approximately 6 days only<strong>of</strong> dermatology education. The BAD campaigns formore and better undergraduate and GP training indermatology. <strong>Consultant</strong>s conduct assessments (such asmini-clinical evaluation exercise (mini-CEX), directobservation<strong>of</strong>proceduralskills(DOPs))fortraineedermatologists, SAS, and foundation year 1 and 2 (FY1and FY2) doctors and medical students. Entry todermatology training requires pr<strong>of</strong>iciency in coreinternal medical training, including passing the MRCPqualification. Trainee dermatologists follow a 4-yearcurriculum, overseen by the specialist advisorycommittee (SAC), encompassing all aspects <strong>of</strong>dermatology.Mentoring and appraisal <strong>of</strong> medical and otherpr<strong>of</strong>essional staffThe UK leads the world in development <strong>of</strong> specialistdermatology nurses.Continuing pr<strong>of</strong>essional developmentDermatologists spend more than 50 hours per year oncontinuing pr<strong>of</strong>essional development (CPD).Clinical governanceClinical governance meetings discussing outcomes andreviewing departmental data, audit, complaints, newguidelines, etc should be included in the workprogramme. Protected time should be allowed for local,regional and national audit.Research – clinical studies and basic scienceClinical and basic science research is essential to driveinnovation and improve outcomes. The UK84 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties DermatologyDermatology Clinical Trials Network has over 600members. Academic dermatologists contribute to NHSwork by setting up tertiary services, and leading UKdermatology education and research. The second largestcharity for dermatology research, the British SkinFoundation, is funded and supported by the BAD,which has also set up, in 2012, a network fortranslational dermatology research. The NIHRDermatology Specialty Group is being reorganised in2013 and supports delivery <strong>of</strong> clinical dermatologyresearch studies on the NICE research portfolio.Local management rolesDermatologists have multiple roles, leading clinicalareas such as paediatric dermatology or patch testingand being responsible for registrar training orundergraduate teaching, audit and clinical governance.They also may be MDT chair or clinical service lead.Regional and national workMedical representation is essential on local, regionaland national committees, and for national, pr<strong>of</strong>essionalor governmental bodies such as the DH, GMC, SAC, theRCP and the British Medical Association (BMA). TheBAD has elected <strong>of</strong>ficers and committees that contributesubstantially to national policy. Appropriate timeshould be allocated in the work programme for theseimportant roles if the NHS is to function efficiently.The British Journal <strong>of</strong> Dermatology and Clinical andExperimental Dermatology, essential for servicedevelopment and CPD, are run by the BAD, <strong>with</strong>editorial work and paper reviews undertaken by UKdermatologists.National guidelinesNational guidelines are produced by dermatologists andlisted on www.bad.org.uk,badgedbyNHSEvidence.Dermatologists contribute to NICE appraisals andguidelines and NHS ‘Clinical knowledge summaries’.Audits, quality tools and frameworksAll dermatologists participate in local, regional andnational audit programmes, and many help developquality tools and service frameworks.6 Clinical work <strong>of</strong> consultants indermatologyInpatient workIn many hospitals, dermatology care is moving from afixed ward base to multidisciplinary involvement <strong>with</strong>dermatology <strong>patients</strong> on multiple wards. This must bereflected in job plans, <strong>with</strong> in<strong>patients</strong> also receivingexpert, dedicated dermatological nursing care. Ward rounds, leading and training a team includingregistrars, specialist nurses and students, usuallyoccur for dermatology in<strong>patients</strong> twice weekly. Referral work. Urgent requests for dermatologicalopinions on acute admissions require review onward rounds. These frequently reduce length <strong>of</strong> stayin hospital.Outpatient and day-case workOutpatient and day-case work is the core work <strong>of</strong> mostdermatologists. The nature <strong>of</strong> these clinics and specialistprocedures varies considerably. General dermatology clinics: the ratio <strong>of</strong> new t<strong>of</strong>ollow-up <strong>patients</strong> and time allocated varydepending on the type/complexity <strong>of</strong> the cases seen.On average 12–16 <strong>patients</strong> may be seen in a clinic. Inclinics teaching undergraduates, training registrars,or supervising doctors and nurses, numbers must bereduced accordingly. Skin cancer/‘see-and-treat’ clinics: variousmodelsareused. In screening clinics dermatologists see largernumbers <strong>of</strong> <strong>patients</strong>. See-and-treat clinics providesurgery on the first visit, reducing the numbers seen. Specialised clinics <strong>with</strong>in dermatology includepaediatrics, skin allergy, photodermatology andgenital clinics. Complex case clinics: regions and large departmentshold multidisciplinary clinics weekly or monthly forcomplex cases. Surgery lists may include biopsies (<strong>of</strong>ten done bynurses), day-case skin surgery lists including Mohs’micrographic surgery and laser lists (requiring alaser-safe area and general anaesthetic facilities forchildren). Skin surgery will usually take 20 minutesfor a skin biopsy, 30 minutes for a simple excisionand 60–90 minutes for more complex flaps and graftrepairs. Micrographic surgery can take 90 minutes toseveral hours. These times do not include‘turnaround’ time between cases, which depends ontrained nursing support and efficiency.Specialist on callDermatology trainees require training in acute ‘on-call’dermatology. Patients <strong>with</strong> severe skin disease or skinfailure should have access to expert dermatologyadvice.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 85


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Other specialist activitiesOther specialist activities include weekly 1–2 hour MDTcancer meetings reviewing cancer cases according to theNICE guidelines, cancer networks, case conferences andnationally commissioned specialist services.Clinically related administrationClinically related administration includes screening andprioritising referral letters, reviewing and acting uponlaboratory results and communicating <strong>with</strong> and about<strong>patients</strong> <strong>with</strong> colleagues in writing, by telephone oremail. The time ratio between direct patient contactand clinical administration for dermatologistsis 1:0.4.TeledermatologyTeledermatology may be a useful triage tool forgeographically remote areas only as part <strong>of</strong> an integratedconsultant-led team subject to full clinical governance;there is no evidence that it can safely reduce referralsoutside this setting. 11 Quality standards forteledermatology have been produced in 2012–13 by amultistakeholder group, supported by the DH, to guidecommissioners. These standards should be available onthe Primary Care Commissioning website and onwww.bad.org.uk in 2013 (personal communication, JanMcLelland, honorary secretary, BAD).7 Opportunities for integrated care andcontinuity<strong>Consultant</strong> dermatologists are the most efficientproviders <strong>of</strong> skin care. Due to consultant shortages inthe UK, dermatology services work most efficiently asinterdisciplinary, consultant dermatologist-led teamsincluding SAS doctors, GPs and nurses (in secondaryand intermediate care). GPwSIs must comply <strong>with</strong> DHrules on training and governance. 168 Workforce requirements for the specialtyBased on government statistics for new patient referralsin 2009–10, a population <strong>of</strong> 250,000 generates 4,000new <strong>patients</strong>. 5 With a ratio <strong>of</strong> 1 new to 1.6 follow-up<strong>patients</strong> achievable for general dermatology clinics (notcounting <strong>patients</strong> attending for patch testing,phototherapy, surgery and other specialist treatmentsthat should be separated and removed from thisstatistic), 17 6,400 follow-up <strong>patients</strong> would give 10,400<strong>patients</strong> per year in total.The recorded new to follow-up ratio in 2009–10 fordermatology in England was 1:2.1. 5 Commissionersusing current recording methods should expect thesefigures.Activities related to direct clinical care generateapproximately 0.4 PA (programmed activity) for eachclinic (Table 1). A 10-PA consultant should work 5 PAsin the clinic, operating theatre, seeing ward <strong>patients</strong>, etc,<strong>with</strong> 2 PAs <strong>of</strong> patient administration and 0.5 PA forMDT. A newly appointed consultant on 8.5 DCC and1.5 SPA (ie <strong>with</strong> no teaching, research and traineesupervision or department management) may do anextra 0.7 PA in clinic or operating (<strong>with</strong> an extra0.3 patient admin) initially pending job planningreview.A consultant <strong>with</strong> no travel to other centres, noin<strong>patients</strong>, ward rounds or on call, no specialist clinics,no clinic teaching and no junior supervisory role shouldundertake2new,2follow-up(orequivalentmixedclinics) and 1 skin surgery clinic per 10-PA week. With12 new <strong>patients</strong> (20 minutes per consultation), 16follow-up cases (15 minutes per consultation) or up to 7surgical cases per clinic, 24 new <strong>patients</strong>, 32 follow-up<strong>patients</strong> and 7 surgical procedures are seen per week.These are maximum numbers; actual numbers andnew:follow-up ratios vary according to casetype/complexity, <strong>with</strong> a ratio <strong>of</strong> 1:1.6 reported forpsoriasis. 18 People attending phototherapy, day care,treatment visits, surgery or investigations should notcount or be coded as follow-up cases. Intermediateservices take simple cases, resulting in more complexcases in secondary care adversely affecting new t<strong>of</strong>ollow-up ratios.In an average 42-week year, a consultant will see 1,008new and 1,344 follow-up <strong>patients</strong> and perform 280operations. A population <strong>of</strong> 250,000, therefore, requires4 whole-time equivalent (WTE) consultants (ie oneconsultant per 62,500 based on DH 2009–10 figures).This does not allow for specialist clinics, teachingstudents, supervising or training any grade <strong>of</strong> staff, wardreferrals, inpatient care, on-call work, travel or MDTs.There were 655 (557 WTE) consultant dermatologists,213 WTE specialty registrars (equivalent to 44 WTEconsultants) and 157.3 WTE SAS doctors (equivalent to125 WTE consultants) in the 2012 UK BAD workforcesurvey, totalling approximately 726 WTE consultants.For the population <strong>of</strong> 61,800,000 6 the UK workforcerequirement for a consultant-led service is a minimum86 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties DermatologyTable 1 Example <strong>of</strong> job plan (England)Activity Workload Programmed activities (PAs)Direct clinical careWard rounds, day-care supervision, nurseclinic supervision, ward referrals inhospitals <strong>with</strong> contractual agreementsGeneral outpatient clinicsReferrals from hospital colleagues;inpatient bed numbers vary12 for new clinic (20 min/consultation) or16 follow-ups (15 min) or combination0.5–1.53–4Skin surgery 7 cases <strong>of</strong> average complexity 0–1Skin cancer multidisciplinary team Weekly or alternate weeks 0.5–1Dermatopathology Variable 0–0.5On-call duties Variable 0–1Administration and managementSpecialist clinics‘Choose and book’, direct patient care,review <strong>of</strong> results, communication <strong>with</strong>other, healthcare pr<strong>of</strong>essionals (0.4 perclinic or surgical list)eg paediatric, patch testing,phototherapy, psoriasis, skin cancer2–2.50–2Travel Variable 0–1Total number <strong>of</strong> direct clinical care PAs7.5 on averageSupporting pr<strong>of</strong>essional activities(SPAs)Work to maintain and improve thequality <strong>of</strong> healthcareOther NHS hospital responsibilitiesExternal dutiesRevalidation, undergraduate education,nurse, GP and hospital doctor trainingand supervision, appraisal educationalsupervisor or programme director forspecialty registrars; departmentalmanagement and service developmentaudit and clinical governance CPD andrevalidation, research, etcMedical director/clinical director/leadconsultant in specialty/clinical tutorWork for deaneries/royalcolleges/specialist societies/DH or othergovernment bodies2.5 on average (1.5 minimum forrevalidation if no teaching/research/trainee supervision/departmentmanagement)Local agreement <strong>with</strong> trustTime for this has been agreed by NHSleaders<strong>of</strong> 989 (WTE) dermatologists, indicating a shortfall <strong>of</strong>over 250 WTE dermatology consultants.Reductions in clinic numbers are required forconsultants supervising and training other doctors andmedical students. The impact varies (typically onepatient slot/individual) but may mean up to a 30%reduction in patient numbers.9 <strong>Consultant</strong> work programme/specimenjob planThe work programme/specimen job plan discussed hereis for a consultant dermatologist <strong>working</strong> in a districtgeneral hospital. The standard contract for a full-timeNHS consultant is 10 PAs per week, typically dividedinto 7.5 PAs for direct patient care including ward workC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 87


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>and 2.5 PAs for supporting activities (SPAs) (7:3 ratio inWales).The balance <strong>of</strong> formal clinics, surgery, specialist clinics,ward work and supervisory activity will vary. Directpatient contact time must be accompanied byappropriate clinical administration time (1 clinical PArequires 0.4 PA administration time).Numbers in clinics should be adjusted to ensurecompletion <strong>with</strong>in 4 hours (3.75 in Wales), includingclinic teaching and immediate clinical administration.The BMA and the RCP give 2.5 SPAs (3 in Wales) as the‘typical’ requirement, <strong>with</strong> 1.5 typically needed for thepurposes <strong>of</strong> revalidation. Additional time is required fortraining, the lead dean stating that StR supervisionrequires 0.5 SPA and FY1/FY2 supervision 0.25 SPAweekly. New jobs should detail the proposed SPAs andexisting consultants may need to justify SPAs at the jobplan review.Work for national bodies should be acknowledged andprogrammed and may require a negotiated reduction inthe clinical elements <strong>of</strong> the job plan. On-callcommitments will vary <strong>with</strong> local policies and staffinglevels. Those <strong>working</strong> part-time or in academic postsmust revalidate. Adequate SPA time must, therefore, beavailable while maintaining a sensible balance in apart-time contract. Hospital consultants involved inteaching and research need additional time for theseactivities, which will reduce the clinical elements <strong>of</strong> thejob plan.10 Key points for commissioners <strong>of</strong>dermatology services1 Dermatology care should always be delivered byindividuals <strong>with</strong> the right skills, in the right setting,the first time.2 Patients <strong>of</strong>fered choice should receive fullinformation about the qualifications, accreditationand range <strong>of</strong> services <strong>of</strong>fered by providers.3 Dermatologists manage diseases <strong>of</strong> the skin,hair and nails in adults and children. As over2,000 conditions are recognised, accuratediagnosis is fundamental to successfulmanagement.4 Each year 54% <strong>of</strong> the population are affected byskin disease, and 23–33% at any one time havedisease that would benefit from medical care. 1,2 5678910References123Skin cancer is the most common cancer and thesecond most common cause <strong>of</strong> death in youngadults. Basal cell carcinoma numbers equal allother malignancies combined and increased by81% between 1999 and 2010. 3 Reportedmelanoma incidence increased by 50% over13 years. 4<strong>Consultant</strong> dermatologists see over 1,000 new<strong>patients</strong> per year and provide expert management,leading and training an MDT <strong>of</strong> dermatologynurses and GPs <strong>working</strong> across traditionalhealthcare boundaries. Efficiency <strong>of</strong> consultants ismaximised by support and teamwork <strong>with</strong>specialist nurses and secretaries, optimisingcommunication <strong>with</strong> the public and otherpractitioners.Thereisnoevidencethatintermediatecareindermatology saves money or reduces referrals tosecondary care, although such services may bepopular <strong>with</strong> <strong>patients</strong>. 7,8 There are DH documentson GPwSI training and governance that should befollowed for patient safety. 1 DH training andgovernance guidance (2010–11) for GPwSI surgeryfor low-risk skin cancers should be followed.Teledermatology may be a useful triage tool forgeographically remote areas but only as part <strong>of</strong> anintegrated consultant-led team subject to fullclinical governance; there is no evidence that it cansafely reduce referrals outside this setting. 16Dermatology consultants should not work inisolation but <strong>with</strong> consultant colleagues <strong>with</strong> arange <strong>of</strong> subspecialist skills.The British Association <strong>of</strong> Dermatologists clinicalservices unit (www.bad.org.uk)providesclear,evidence-based guidance 19 andisabletoadvisecommissioners about dermatology services andhelp resolve issues.Sch<strong>of</strong>ield JK, Grindlay D, William HC. Skin conditions inthe UK: a health needs assessment. 2009.www.nottingham.ac.uk/scs/divisions/evidencebaseddermatology/news/dermatologyhealthcareneedsassessmentreport.aspx [Last accessed 26 January 2013].Proprietary Association <strong>of</strong> Great Britain and ReadersDigest. A picture <strong>of</strong> health: a survey <strong>of</strong> the nation’sapproach to everyday health and wellbeing.London:Proprietary Association <strong>of</strong> Great Britain, 2005.Levell NJ, Igali L, Wright KA, Greenberg DC. Basal cellcarcinoma epidemiology in the UK: the elephant in theroom. Clin Exp Dermatol 2013; Mar 18.doi:10.1111/ced.12016.88 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Dermatology4 Parkin DM, Mesher D, Sasieni P. Cancers attributable tosolar (ultraviolet) radiation in the UK in 2010. Br JCancer 2011;105:S66–9.5 Hospital Episode Statistics Online. www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=892 [Last accessed 26 January 2013].6 Revised guidance on GPwSI dermatology and skinsurgery services 15 April 2011. gp.dh.gov.uk/2011/04/15/revised-guidance-on-gpwsi-dermatology-and-skinsurgery-services[Last accessed 24 January 2013].7 DH Long Term Conditions Care Group. www.bad.org.uk/Portals/ Bad/Official%20Responses/Service%20models%20fig%20and%20evidence.pdf [Last accessed26 January 2013].8 Levell NJ, Penart-Lanau AM, Garioch JJ. Introduction <strong>of</strong>Intermediate Care Dermatology Services in Norfolk,England was followed by a 67% increase in the referralsto the local secondary care dermatology department. Br JDermatol 2012;167:443–5.9 Office for National Statistics. Population statistics, June2010. Statistical Bulletin. www.ons.gov.uk/ons/rel/popestimate/population-estimates-for-england-and-wales/mid-2002-to-mid-2010-revised–national-/stb—mid-2002-to-mid-2010-revised-population-estimates-forengland-and-wales.html[Last accessed 26January 2013].10 British Association <strong>of</strong> Dermatologists and BritishPhotodermatology Group. Working party report onMinimum Standards for Phototherapy Services.www.bad.org.uk/Portals/ Bad/Clinical%20Services/BAD%20Working%20Party%20Report%20on%20Phototherapy%20Services%202011v8%20final%20draft%20Logo.pdf [Last accessed 26 January 2013].11 British Association <strong>of</strong> Dermatologists and British Societyfor Paediatric Dermatology. Working party report onMinimum Standards for Paediatric Services, 2012.www.bad.org.uk/Portals/ Bad/Clinical%20Services/Paediatric%20Working%20Party%20Report%20Final%20Draft%20V11(1).pdf [Last accessed 26 January 2013].12 British Association <strong>of</strong> Dermatologists and British Societyfor Cutaneous Allergy. Working party report on MinimumStandardsforCutaneousAllergyServices.www.bad.org.uk/Portals/ Bad/Clinical%20Services/BAD%20%20BSCA%20Working%20Party%20Report%20on%20Cutaneous%20Allergy%20Services%202012%20Final(1).pdf [Last accessed 26 January 2013].13 British Association <strong>of</strong> Dermatologists andPsychodermatology UK. Working party report onMinimum Standards for Psycho-Dermatology Services,2012. www.bad.org.uk/Portals/ Bad/Clinical%20Services/Psychoderm%20Working%20Party%20Doc%20Final%20Dec%202012.pdf [Last accessed 26 January 2013].14 Quality Standards for Dermatology: providing the rightcare for people <strong>with</strong> skin conditions. 2011. www.pcc-cic.org.uk/sites/default/files/articles/attachments/quality standads for dermatology report.pdf [Lastaccessed 24 January 2013].15 British Association <strong>of</strong> Dermatologists. Staffing andfacilities for dermatological units, 2006. www.bad.org.uk//site/492/default.aspx [Last accessed 26 January2013].16 British Association <strong>of</strong> Dermatologists. The role <strong>of</strong>teledermatology in the delivery <strong>of</strong> dermatology services,2010. www.bad.org.uk/Portals/ Bad/Clinical%20Services/BAD%20Teledermatology%20Position%20Statement%20rev1%20April%202010.pdf [Last accessed 26 January2013].17 Department <strong>of</strong> Health. Guidance and competencies for theprovision <strong>of</strong> services using GPs <strong>with</strong> special interests(GPwSI) in community settings: dermatology and skinsurgery. London: DH, 2007.18 British Association <strong>of</strong> Dermatologists. Demandmanagement and follow up ratios in dermatology.www.bad.org.uk/Portals/ Bad/Clinical%20Services/BAD%20Demand%20management%20Follow%20Up%20ratios%20guidelines%20August%202009%20v1%200.pdf [Last accessed 26 January 2013].19 British Association <strong>of</strong> Dermatologists. www.bad.org.uk/Portals/ Bad/Clinical%20Services/Guidance%20for%20Commissioning%20Derm%20Services%20v6.pdf [Lastaccessed 26 January 2013].C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 89


2 Specialties Diabetes and endocrinologyDiabetes and endocrinologyPr<strong>of</strong>essor Ge<strong>of</strong>f Gill MSc MD PhD FRCP<strong>Consultant</strong> physician (diabetes and endocrinology)Dr John Newell-Price PhD FRCPReader in endocrinology, consultant endocrinologist1 Description <strong>of</strong> the specialtyThe specialty <strong>of</strong> diabetes and endocrinology deals <strong>with</strong>the diagnosis and management <strong>of</strong> a diverse range <strong>of</strong>hormonal and metabolic disorders. It encompasses awide variety <strong>of</strong> conditions ranging from the mostcommon (eg type 2 diabetes) to those that are rare buteminently treatable (eg pituitary tumours). Mostconditions are chronic, requiring long-term and <strong>of</strong>tenlifelong management. There is a strong evidence basefor the management <strong>of</strong> disorders encountered <strong>with</strong>inthe specialty. Delayed, inadequate or inappropriatetreatment leads to poor health, reduced lifespan andincreased burden on the health service.Main disease patternsType2diabetesisacommonmultifaceteddisorderthatis rapidly increasing in incidence. The demands <strong>of</strong>glucose control management are progressive, andconcurrent management <strong>of</strong> hypertension, obesity anddyslipidaemia is usually required. Type 1 diabetes <strong>of</strong>tenstarts in childhood and is usually compounded byemotional and behavioural problems common toadolescent and young adult medicine. In either kind <strong>of</strong>diabetes, potential complications are protean. Untreatedthey lead to disability and early death.Increasingly the clinical presentation <strong>of</strong> type 1 and type2 diabetes is becoming more complex. There is growingrecognition <strong>of</strong> the monogenic varieties <strong>of</strong> diabetes andtherefore diagnosis <strong>of</strong> the type <strong>of</strong> diabetes is becomingmore difficult. There is also a greater emphasis onpatient empowerment and education, <strong>with</strong> increasingdevelopment <strong>of</strong> newer treatment options such asthiazolidinediones (TZDs), glucagon-like peptide(GLP1) analogues, dipeptidyl peptidase-IV (DPP IV)antagonists, newer insulins and insulin pumps. Theproblems <strong>of</strong> diabetes in pregnancy have been outlinedin the Confidential Enquiry into Maternal and ChildHealth (CEMACH) report (www.cemach.org.uk). Withthe increasing prevalence <strong>of</strong> obesity and type 2 diabetesin women <strong>of</strong> childbearing age this problem is going togrow.Endocrinology covers disorders <strong>of</strong> the endocrine glands,in particular the thyroid, pituitary and adrenal glands,testes and ovaries. Thyroid disorders are the mostcommon, usually presenting as under-activity(hypothyroidism) or over-activity (thyrotoxicosis).2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralSources <strong>of</strong> referral from primary, secondary andtertiary levelsDiabetes servicesDiabetes services are largely outpatient based. Acomplex local network <strong>of</strong> services is required toencompass the needs <strong>of</strong> all people <strong>with</strong> diabetesthroughout their lifelong pathway <strong>of</strong> care. Much <strong>of</strong>the process <strong>of</strong> care can be provided in primary careby nurses, dietitians, podiatrists and GPs. A corerequirement for all <strong>patients</strong> is self-care, whichnecessitates effective, ongoing patient educationprogrammes. The majority <strong>of</strong> diabetes care is inprimary care, but specialist input is required tosupport the primary care team <strong>with</strong> clinicaladvice and education for health pr<strong>of</strong>essionals and<strong>patients</strong>.At various stages, further specialist physicianmanagement is required: at the time <strong>of</strong> transitions: eg new diagnosis <strong>of</strong> type 1diabetes, younger type 2 <strong>patients</strong>, monogenicdiabetes or the progression to more complex therapyfor someone <strong>with</strong> poorly controlled type 2 diabetes in particular clinical scenarios: eg young people <strong>with</strong>diabetes, diabetic pregnancy, metabolic emergencies,C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 91


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>serious intercurrent non-diabetic illness orpsychosocial interactions for the identification and collaborative management<strong>of</strong> complications: eg severe diabetic foot disease,diabetic nephropathy, erectile dysfunction, painfuland autonomic neuropathy, or macrovasculardisease.Rapid changes in the structure and delivery <strong>of</strong> servicesare occurring as a result <strong>of</strong>: treatment developments such as continuoussubcutaneous insulin infusion technological developments such as remotelyaccessed blood glucose results, call-centre supportand electronic care records GPs <strong>with</strong> a special interest (GPwSIs) in diabetes changing organisational relationships andcommissioning in primary and secondary care structured educational programmes relationships <strong>with</strong> acute medical care and generalmedicine.Endocrine servicesFor common conditions, such as polycystic ovarysyndrome (PCOS) and thyroid disorders, services are<strong>of</strong>ten organised on a multidisciplinary or multisectorbasis, which is much less complex but in other respectssimilar in structure to that for diabetes. Unusualendocrine disorders require sophisticated laboratoryand clinical imaging support for diagnosis and closeliaison <strong>with</strong> highly specialised surgical services fortreatment. In England From April 2013 these will fallunder the remit <strong>of</strong> the specialised services nationaldefinitions set, and be commissioned nationally(www.specialisedservices.nhs.uk).3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong>Involving <strong>patients</strong> in decisions abouttheir treatmentTreatment choices in diabetes and endocrinology are<strong>of</strong>ten complex and entail difficult risk assessments.Lengthy, well-informed negotiation between specialistsand <strong>patients</strong> is necessary in order to achieve optimumoutcome. Young people <strong>with</strong> diabetes and endocrinedisorders require support and negotiated managementappropriate to their stages <strong>of</strong> physical and emotionaldevelopment. Long-term clinical records areindispensable; ideally, they should integrate informationand results from all the healthcare providers and beaccessible to both pr<strong>of</strong>essionals and <strong>patients</strong>.Access to information, opportunities foreducation and promoting self-careDiabetes is always a chronic condition and manyendocrine disorders are also lifelong. Therefore,self-care and empowerment are a core part <strong>of</strong> deliveringthe appropriate services. Patient education programmesare an essential component <strong>of</strong> management for type 1and type 2 diabetes, and feature increasingly in themanagement <strong>of</strong> endocrine conditions such as PCOS,pituitary disease and hypogonadism. National and localpatient organisations are prominent and supportive inthese areas.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong> and <strong>working</strong> <strong>with</strong>other specialtiesMultidisciplinary team (MDT) <strong>working</strong> andcollaboration <strong>with</strong> other specialists is a characteristic<strong>of</strong> almost all aspects <strong>of</strong> diabetes and endocrinespecialist care.The diagnosis and ongoing care <strong>of</strong> children, youngpeople and adults <strong>with</strong> type 1 diabetes demand closecollaboration among paediatricians, paediatric diabetesspecialist nurses, <strong>physicians</strong> <strong>with</strong> a special interest indiabetes, adult diabetes specialist nurses and dietitians,and, <strong>of</strong>ten, contributions from podiatrists, optometristsand psychologists. For type 2 diabetes, primary careteams make the majority <strong>of</strong> the diagnoses and providethe ongoing care. Specialist services provideconsultative advice at intervals and, at times, temporaryongoing care for particularly difficult metabolic orcomplicated management problems. Specialist serviceswill be increasingly involved in the ongoing education<strong>of</strong> the primary care teams.Diabetic foot care requires an extensive MDT includingcommunity podiatrists and district nurses, hospitalpodiatrists, orthotists, microbiologists, vascularsurgeons and orthopaedic surgeons, in addition todiabetes specialist nurses and physician specialists.Diabetes pregnancy care requires integrated team<strong>working</strong> <strong>with</strong> obstetric and midwifery colleagues.Other aspects <strong>of</strong> diabetes care involve collaborativemanagement <strong>with</strong> ophthalmologists, nephrologists,92 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Diabetes and endocrinologystroke <strong>physicians</strong>, cardiologists, rheumatologists,emergency care teams, elderly care teams and every kind<strong>of</strong> inpatient hospital care for which people <strong>with</strong> diabetesare admitted. The need to involve such specialties is<strong>of</strong>ten concurrent <strong>with</strong> the need to reconfigure themetabolic care plan.Both diabetes and endocrinology are heavily dependenton close collaboration <strong>with</strong> laboratories. This isparticularly the case for endocrinology where access tospecialist laboratory techniques may determine theability to deliver service. Endocrinology is alsodependent on a variety <strong>of</strong> sophisticated imagingtechniques requiring close collaboration <strong>with</strong> specialistradiologists. For the management <strong>of</strong> pituitary diseaseendocrinologists work in teams <strong>with</strong> neurosurgeons andradiotherapists; for thyroid and adrenal disorderspartnership <strong>with</strong> an endocrine surgical team is essential;for reproductive endocrinology it is necessary to workclosely <strong>with</strong> specialist gynaecologists. Several complexendocrine disorders have their origins in childhood (eggrowth disorders, Turner’s syndrome and congenitaladrenal hyperplasia (CAH)), so liaison between adultand paediatric services during the vulnerable transitionperiod is essential to effective continuing care. Themanagement <strong>of</strong> genetically based endocrine disorderssuch as CAH and multiple endocrine neoplasia willusually involve geneticists. The majority <strong>of</strong> specialistendocrine practice requires specialist nurse support.5 Delivering a high-quality serviceWhat is a high-quality service?High-quality diabetes services should be managed in afully integrated manner that deploys primary,intermediate, secondary and tertiary care facilities inan integrated programme that will achieve all <strong>of</strong> thestandards set out in the national service framework(NSF) for diabetes. Services continually self-assess theirstructures and processes using systems such as Diabetes,and monitor outcomes <strong>of</strong> care throughlocal and national clinical audit (see below). Inendocrinology, as for diabetes, common conditionsneed to be managed collaboratively between primaryand secondary care according to local guidelines and<strong>with</strong> ongoing audit <strong>of</strong> satisfaction and outcome.Regional centres deal <strong>with</strong> the rarer endocrineconditions and should be co-located <strong>with</strong> thelaboratory, imaging and surgical teams in order toprovide a seamless, comprehensive, safe andhigh-quality service.Maintaining and improving the quality <strong>of</strong> careThis work encompasses continuing pr<strong>of</strong>essionaldevelopment (CPD), clinical governance, pr<strong>of</strong>essionalself-regulation, education and training. For manyconsultants, at various times in their careers, it may alsoinclude research, management and providingpr<strong>of</strong>essional advice. Management is a commoncomponent <strong>of</strong> diabetes service provision. The roletypically involves providing whole systems clinical andorganisational leadership across a care communityusually comprising about 250,000–500,000 people andincludes responsibility for the education, developmentand quality assurance <strong>of</strong> primary care and communitystaff and those <strong>working</strong> from a hospital base.Specialty and national guidelinesDiabetes guidance and guidelines The NSF for diabetes www.dh.gov.uk/en/Healthcare/NationalServiceFrameworks/Diabetes NICE guidance: technology appraisalswww.nice.org.uk NICE clinical guidelines www.nice.org.uk National audit www.diabetese.net Diabetes in pregnancy www.cemach.org.uk Specialist societies: Diabetes UKwww.diabetes.org.uk and the Association <strong>of</strong>British Clinical Diabetologists (ABCD)www.diabetologists.org.uk <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP)www.rcplondon.ac.ukEndocrinology guidance and guidelines NICE guidance: technology appraisals for theuse <strong>of</strong> growth hormone: www.nice.org.uk/catrows.asp?c=153 National guidelines containing standards againstwhich practice can be audited: Society forEndocrinology (www.endocrinology.org/index.aspx); these include recent position statements, egon testosterone replacement and dopamine agonists The RCP guidelines on pituitary tumours, thyroidcancer and radioactive iodine http://bookshop.rcplondon.ac.uk International guidelines: Endocrine Societywww.endo-society.org6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialtyMost consultants <strong>with</strong> a specialist interest in diabetesand endocrinology work in acute hospitals. TheyC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 93


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>contribute substantially to provision <strong>of</strong> the acutegeneral medical service. Usually they participate in aone in eight to one in fourteen acute-take rota thatincludes post-take ward rounds on the emergencymedical admissions unit. Additionally, they will lead award-based team responsible for about16–20 unselected general medicine in<strong>patients</strong>.Most diabetes/endocrine consultants are also trained ingeneral medicine and take part in acute medicine ‘takes’on a rotational basis. A small number <strong>of</strong> consultantsmay deal <strong>with</strong> diabetes <strong>with</strong>out endocrinology, and asomewhat larger number may be endocrine specialistsalone. There is an increasing number <strong>of</strong> diabetologists<strong>with</strong> a community diabetes specialty.Inpatient workDiabetes is over-represented in hospital populations(about 17% <strong>of</strong> NHS beds are occupied by diabetic<strong>patients</strong>), mostly due to complications such as coronaryartery disease or foot ulceration <strong>with</strong> infection.Treatment alterations and glycaemic control are doneon an outpatient basis by diabetes specialist nurses.Similarly, endocrine investigation and treatment arealmost entirely done <strong>with</strong>out hospital admission.Diabetes/endocrine specialists therefore have anunusually high inpatient load <strong>of</strong> general medical, ratherthan specialty, <strong>patients</strong>. Diabetic foot disease (the mostcommonly admitted diabetes-related disorder) is alsoincreasingly managed on an outpatient basis <strong>with</strong> thesupport <strong>of</strong> multidisciplinary foot care teams. Inpatientconsultation work varies considerably depending on theco-specialty pr<strong>of</strong>ile <strong>of</strong> the hospital. Because <strong>of</strong> the highprevalence <strong>of</strong> diabetes comorbidity among hospitalin<strong>patients</strong>, there is a substantial workload in supportingcolleagues in other specialties; this is increasedconsiderably if there are tertiary referrals: maternity,renal, vascular or cardiac services. 1 For endocrinology,the workload is greater where a hospital hasneurosurgery, a cancer centre or a specialist endocrinesurgical service.Outpatient workOutpatient work comprises the following elements: General internal medicine (GIM): this load variesconsiderably. Most consultants will either run aseparate general medical clinic or see such <strong>patients</strong>as part <strong>of</strong> their endocrine clinic. Diabetes services: new patient consultations forpeople <strong>with</strong> diabetes are complex and requireapproximately 30 minutes <strong>of</strong> consultation time.Review diabetes <strong>patients</strong> require approximately20 minutes but may require more time. Additionaltime <strong>with</strong> other healthcare pr<strong>of</strong>essionals (egspecialist nurses and dietitians) may also be needed. Endocrine services: new endocrine <strong>patients</strong> requireabout 30 minutes <strong>of</strong> consultation time and review<strong>patients</strong> about 15 minutes. Complex reviews forpituitary <strong>patients</strong> or endocrine tumours, paediatrictransition or genetic consultations may take longerand arrangements for joint consultation <strong>with</strong> otherspecialities are recommended. Nurse-led clinics: increasingly specialist services anddiabetes and endocrinology are being provided bynurse-led clinics. These are an invaluable resourcethat ensure that the appropriate review <strong>of</strong> many<strong>patients</strong>. They do, however, still require consultantsupport.Academic medicinePhysicians in the specialty who have university contractsgenerally divide their time equally between research anda clinical work programme similar in configuration butreduced by 50% <strong>of</strong> the volume to their NHS colleagues.Quite frequently, the clinical contribution will berestricted to the specialty (eg no GIM, or onlyendocrinology). The academic component <strong>of</strong> such postsusually focuses primarily on research, but there is likelyto be a substantial teaching load and other academic,administrative and managerial responsibilities.7 Opportunities for integrated careThese have been partly covered in section 4. Examples<strong>of</strong> integrated care in the specialty <strong>of</strong> diabetes andendocrinology include: the diabetes team: consultant, specialist nurse,dietitian and podiatrist the extended diabetes team: vascular surgeon,orthopaedic surgeon, nephrologist,ophthalmologist, optometrist, psychologist, etc diabetes links <strong>with</strong> primary care, includingcommunity diabetologists and GPwSIs in diabetes endocrine links <strong>with</strong> nuclear medicine (fortreatment <strong>of</strong> thyrotoxicosis): endocrine surgeons,geneticists and paediatricians joint management <strong>of</strong> <strong>patients</strong> <strong>with</strong> pituitary disease<strong>with</strong> pituitary surgeons, in pituitary centres transitional care (in both diabetes andendocrinology) for the efficient and sensitive movefrom paediatric to adult care.94 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Diabetes and endocrinology8 Workforce requirements for the specialtyCurrent workforce numbersThe 2011 annual Diabetes UK RCP manpower surveyidentified 723 whole-time equivalent (WTE)consultants in the UK. These numbers give WTEconsultants per 100,000: England 1.1, Scotland 1.51,Wales 1.4 and Northern Ireland 1.67. This represents asmall overall increase in WTEs in the UK, from 1.04 in2009 to 1.16 in 2011. The number <strong>of</strong> consultants<strong>working</strong> single-handedly in hospitals is very small.There has been a rise in the numbers <strong>of</strong> postscombining acute medicine and diabetes and/orendocrinology that appears to reflect a lack <strong>of</strong> vacanciesin recent years in the specialty.Estimated number <strong>of</strong> consultants needed toprovide a specialist service for a population <strong>of</strong>250,000There has been a considerable increase in type 2diabetes prevalence and the prospect <strong>of</strong> formalscreening for diabetes is likely to result in a steep rise indemand for diabetes care; epidemiological studiessuggest that screening may double the number <strong>of</strong> thoseidentified as having diabetes. The latest DiabetesPrevalence Model (2010) from the Association <strong>of</strong> PublicHealth Observatories estimates that the prevalence <strong>of</strong>diabetes will be 8% in England by 2015.Current healthcare policy is to encourage thedevelopment <strong>of</strong> ongoing primary and intermediate carefor diabetes services. These services will, however,require support and supervision from specialists. Thecombination <strong>of</strong> these factors makes it difficult toaccurately calculate the need for specialist andsecondary diabetes care. The best current estimate isthat the increased prevalence and longevity <strong>of</strong> people<strong>with</strong> diabetes and the increased complexity <strong>of</strong> care, plusthe provision <strong>of</strong> new care models, will mean an increasein the workload <strong>of</strong> diabetes specialists. The work <strong>of</strong> thespecialist is likely to change over time, <strong>with</strong> moreemphasis on work outside secondary care but also anincrease in work focused on in<strong>patients</strong> <strong>with</strong> diabetes.For endocrinology, it is also expected that thedevolution <strong>of</strong> more routine care will be balanced by theincreased complexity <strong>of</strong> treatment options for rareconditions. Table 1 shows a recommendation <strong>of</strong> whatcould be regarded as the minimum involvement indiabetes and endocrinology to provide a service for a250,000 population. It is expressed as time divided intoprogrammed activities (PAs) (4-hour sessions). Thisanalysis is for a consultant-provided service and doesnot accurately take outpatient activity by other gradesinto account. The demands <strong>of</strong> acute medicine onspecialty registrars (StRs) and the need to supervisejuniors mean that most consultants feel that it is notpossible to quantify the input from them. Some centresrun parallel nurse-led clinics, which are not included.Table 1 shows that for the specialty commitment alonefor a 250,000 population there is a need for at least 4consultants in endocrinology and diabetes, <strong>with</strong> a10-PA contract allowing for a GIM/acute medicinecomponent and for supporting pr<strong>of</strong>essional activities.No allowance has been made for managerial, regional ornational roles. This would require 877 WTEs atconsultant level for England and Wales (609 in 2011).9 <strong>Consultant</strong> work programme/specimenjob planThe programme in Table 2 assumes the above estimatednumber <strong>of</strong> <strong>physicians</strong> sharing a general medicalcommitment and <strong>working</strong> a 10-PA contract. This wouldfit a typical district general hospital in diabetes andendocrinology and would be different for morespecialised or academic posts. Many <strong>of</strong> the activities aregiven as a range because individual posts will varywidely even in a single department.10 Key points for commissioners1 Diabetes is rapidly increasing in prevalence,consumes about 10% <strong>of</strong> NHS resources and usesabout 17% <strong>of</strong> NHS beds.2 Many diabetic <strong>patients</strong> (eg those <strong>with</strong>uncomplicated type 2 diabetes) can be cared for inprimary care.3 Nevertheless, many will need secondary carespecialty teams. These include most type 1 andcomplex type 2 <strong>patients</strong>.4 Mandatory areas for secondary care includediabetic pregnancy, transitional (adolescent) careand diabetic foot ulceration.5 Secondary care will also lead complex newtreatments, eg insulin pumps, GLP1 agonists.6 Educational systems (eg DAFNE, DESMOND andXPERT) need support in both primary andsecondary care.7 A smooth interface for diabetes care betweenprimary and secondary care is vital and will behelped by community diabetologists and GPwSIs.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 95


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Minimum requirements for a diabetes and endocrinology service for 250,000 people in 2015District population 250,000Diabetes prevalence <strong>with</strong> 0.3% increase/year 8%Number <strong>of</strong> people <strong>with</strong> diabetes 20,000Approximate number <strong>with</strong> type 1 diabetes 2,000Approximate number <strong>with</strong> type 2 diabetes 18,000General diabetes clinics ∗New and follow-up <strong>patients</strong>, including, where necessary, specialist clinics, eg pumps(4–8 clinics)(This figure is dependent on the level <strong>of</strong> additional clinical support, including specialty registrars (StRs),doctor support networks (DSNs), GPwSIs and staff grades. In an increasingly consultant-led service thehigher figure is probably more accurate)Programmed activities(PAs) per week8Community support clinic (primary care, intermediate care, email and ethnic minorities) 2Specialist diabetes clinics ∗Antenatal 1.5Young adult 0.5Paediatrics 0.5Renal/cardiovascular 1Foot 1Ophthalmic 0.5Inpatient care – daily input to admission units and at least two ward rounds per week (this is foremergency specialty care only, not acute GIM. It will require DSN support)2Trainee specialist and practice nurse support 0.5Patient education 1Diabetes network management 1Supervision <strong>of</strong> trainees 1Endocrine outpatient activity ∗New and follow-up patient clinics 4Specialist/joint clinics (one clinic weekly) 1Supervision and training <strong>of</strong> nurse-led clinics 0.5MDM-radiology/biochemistry/histopathology 0.5Supervision <strong>of</strong> trainees 1General/acute medical activityWard rounds, on call etc 4Subtotal 31.5Add allowance for supporting pr<strong>of</strong>essional activity (+ 25% <strong>of</strong> total) 8Total 39.5∗ Clinic allowances include provision for out-<strong>of</strong>-clinic administration.AAU = acute assessment unit; GIM = general internal medicine; GPwSI = general practitioner <strong>with</strong> specialist interest.96 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Diabetes and endocrinologyTable 2 Example <strong>of</strong> a consultant work programmeProgrammedActivity Workload activities (PAs)Direct clinical careWard rounds, referrals, on call 20–25 <strong>patients</strong> 1–3.5Outpatient clinicsDiabetes 4 new and 6 follow-up or 12 follow-up <strong>patients</strong> 1–4.5Endocrinology 4 new and 8 follow-up or 16 follow-up <strong>patients</strong> 0.5–3.5Specialist clinics: diabetes and endocrinology 8 new/follow-up <strong>patients</strong> 1Patient-related and supporting clinical administration 1.5–2.5Patient education, health pr<strong>of</strong>essional education andcommunity support1Total number <strong>of</strong> direct clinical care PAs on average 7.5Supporting pr<strong>of</strong>essional activities (SPAs)Service management: trust and networkWork to maintain and improve the quality <strong>of</strong> healthcareOther NHS responsibilitiesDepartmental management and servicedevelopmentEducation and training, appraisal, audit andclinical governance, continuing pr<strong>of</strong>essionaldevelopment and revalidation,and researchFor example, medical director, clinical director,lead consultant in specialty, clinical tutor <strong>with</strong>trust1.51Local agreement8 Key documents for commissioning diabetesservices are Commissioning diabetes <strong>with</strong>out walls 3and Commissioning specialist diabetes services foradults <strong>with</strong> diabetes. 49 Demand for endocrine services in secondary care isalso increasing, especially <strong>with</strong> regard to thyroiddisease.10 Complex endocrine disease may need relativelyexpensive investigation and treatment (eg growthhormone, octreotide, tolvaptan and cinacalcet),<strong>with</strong> specialist services being commissionednationally (www.specialisedservices.nhs.uk).References1 NHS Institute for Innovation and Improvement.Inpatient care for people <strong>with</strong> diabetes, 2008.www.institute.nhs.uk2 Diabetes UK, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. The DiabetesUK/RCP diabetes and endocrinology national manpowerreport 2012. London: Diabetes UK, 2012.3 NHS Diabetes. Commissioning diabetes <strong>with</strong>out walls.2009. www.diabetes.nhs.uk4 Diabetes UK. Commissioning specialist diabetes servicesfor adults <strong>with</strong> diabetes. 2010. www.diabetes.org.ukC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 97


2 Specialties Gastroenterology and hepatologyGastroenterology and hepatologyDr Adam Harris BSc MBBS MD FRCP <strong>Consultant</strong> physician and gastroenterologist1 Description <strong>of</strong> the specialtyThe specialty <strong>of</strong> gastroenterology and hepatology caresfor <strong>patients</strong> <strong>with</strong> both benign and malignant disorders<strong>of</strong> the gastrointestinal (GI) tract and liver. The specialtyencompasses a wide range <strong>of</strong> conditions – fromcommon disorders, such as indigestion and irritablebowel syndrome, to highly complex problems, such asinflammatory bowel disease (IBD) and liver failure –and specialised procedures such as endoscopic resection<strong>of</strong> cancers and liver transplantation.Gastroenterologists also see <strong>patients</strong> <strong>with</strong> a variety<strong>of</strong> general medical problems, particularly anaemiaand weight loss. Much <strong>of</strong> the work, particularly toexclude organic disease in symptomatic <strong>patients</strong>and to provide rapid diagnosis and treatment for<strong>patients</strong> <strong>with</strong> suspected GI cancer, is based inout<strong>patients</strong>. The investigations required <strong>of</strong>ten includeendoscopy and imaging. An acute and emergencyinpatient service is needed for common problems suchas gastrointestinal haemorrhage, acute IBD anddecompensated liver disease (particularly due toalcohol).Gastroenterologists are involved in the National BowelCancer Screening Programme and provide a highquality,safe, diagnostic and therapeutic (removal <strong>of</strong>polyps) colonoscopy service.Gastroenterology departments have an essential role inthe implementation <strong>of</strong> urgent referral for <strong>patients</strong> <strong>with</strong>suspected cancer (‘2-week referrals’) to improve thediagnosis and treatment <strong>of</strong> GI cancers. Severaldepartments have combined to form multidisciplinaryteams (MDTs) in order to provide the critical mass<strong>of</strong> specialists needed to meet the standards forEngland <strong>of</strong> the Department <strong>of</strong> Health’s (DH’s) ClinicalOutcomes Group (COG) for the provision <strong>of</strong> specialistservices. 1 Tertiary referral units may receive <strong>patients</strong> <strong>with</strong>complex IBD or hepatobiliary disease or complexnutritional problems (who may require home totalparenteral nutrition) or who require advancedtherapeutic endoscopy. Patients who require transplantation <strong>of</strong> theliver and small intestine are referred to the smallnumber <strong>of</strong> units that undertake organtransplantation.Malnutrition is common in hospital <strong>patients</strong>(∼35%) and associated <strong>with</strong> increased morbidityand mortality. 2 Every healthcare facility should bescreening nutritional status using the MalnutritionUniversal Screening Tool (MUST), or equivalent.Patients found to be at risk should ideally bereferred to a multidisciplinary nutrition supportteam.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralMost symptomatic <strong>patients</strong> are looked after by their GP,and most problems are resolved by discussion, primarycare-initiated investigation, advice and medicaltreatment. Nonetheless, there has been a continuingsteady increase in outpatient and inpatient work forgastroenterologists, particularly in relation to alcoholicliver disease and the increasing numbers <strong>of</strong> cancers <strong>of</strong>the GI tract that occur in an ageing population. Theinpatient casemix usually comprises <strong>patients</strong> <strong>with</strong> GIbleeding, cancer, severe alcoholic liver disease and acutesevere IBD.Close liaison <strong>with</strong> colleagues in surgery, radiology,pathology and oncology facilitates the treatment <strong>of</strong>different forms <strong>of</strong> GI disease. Combined outpatientclinics (ie colorectal surgeon and gastroenterologist)undoubtedly improve management, and weekly cancermultidisciplinary team (MDT) meetings are a usefulforum for discussing all complex cases. Meetings <strong>with</strong>radiologists and pathologists should take place at leastonce a week and can be combined <strong>with</strong> formal trainingsessions for trainees.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 99


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Many units have established posts for nursesspecialising in IBD, liver disease, disorders <strong>of</strong> bowelfunction and nutritional support. The specialistnurses are used in the main for task- andprocess-oriented services to streamline clinicalpathways. One effect <strong>of</strong> this is to increase thecomplexity <strong>of</strong> cases for medical staff in clinics. Largerdepartments may employ consultant GI nurses,nurse endoscopists and GPs <strong>with</strong> a special interest(GPwSIs) who will <strong>of</strong>ten carry out sessions in thehospital unit.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcarePatient choice and involving <strong>patients</strong> in decisionsabout their treatmentMuch <strong>of</strong> the outpatient work in gastroenterology relatesto the management <strong>of</strong> chronic conditions such aschronic liver disease and IBD. Success depends on agood <strong>working</strong> relationship <strong>with</strong> the patient, whereby thepatient has a full understanding <strong>of</strong> and participates inthe management <strong>of</strong> their condition and it is clear whereresponsibility lies in patient care for the specialist,patient and GP. An example <strong>of</strong> this is where <strong>patients</strong><strong>with</strong> IBD will <strong>of</strong>ten initiate a change in their treatmentin the face <strong>of</strong> a relapse <strong>of</strong> their disease, usually in closeliaison <strong>with</strong> the specialist team or GP, or both. A furtherexample is the self-help strategies and bi<strong>of</strong>eedback thatare used to treat the highly prevalent symptoms <strong>of</strong> gutdysfunction.Patients are represented on the joint gastroenterology/hepatology committee <strong>of</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong>Physicians (RCP) and, through Crohn’s and Colitis UK(NACC), are involved in the generation <strong>of</strong> standards <strong>of</strong>care for <strong>patients</strong> <strong>with</strong> inflammatory bowel disease.Similarly, <strong>patients</strong> have been involved in settingstandards for nutritional support through Patients onIntravenous and Nasogastric Nutrition Therapy(PINNT) – a core group <strong>of</strong> the British Association forParenteral & Enteral Nutrition (BAPEN). The BritishSociety for Gastroenterology (BSG) endoscopy sectionhas devised comprehensive information leaflets for all<strong>patients</strong> undergoing endoscopy. The British Liver Trustand Core – the main GI charity – also produce manyhelpful documents for <strong>patients</strong>. All <strong>of</strong> the charitablebodies have excellent interactive websites, as does theBSG, <strong>with</strong> a website that has a dedicated patientinformation area.4 Interspecialty and interdisciplinaryliaisonMultidisciplinary teams and <strong>working</strong> <strong>with</strong> otherspecialistsThe practice <strong>of</strong> gastroenterology involves manyspecialties, such as radiology and pathology, andperhaps a greater overlap between medical and surgicalpractice than for any other specialty. This is coordinatedthrough MDT meetings, and facilitating close liaison<strong>with</strong> tertiary referral centres is an integral part <strong>of</strong> themanagement <strong>of</strong> complex GI problems – eg IBD,complex liver disease, pancreatic cancer, liver or smallbowel transplantation, and complex nutritionalproblems that <strong>of</strong>ten require home parenteral nutrition.Specialist nurses in nutrition, stoma care, GI oncology,general gastroenterology and management <strong>of</strong> thetreatment <strong>of</strong> viral hepatitis play an increasingly valuablerole in improving the quality <strong>of</strong> service, communicationand liaison between disciplines <strong>with</strong>in the team.Hospital and community dietitians are vital members <strong>of</strong>the GI team.Working <strong>with</strong> GP specialistsThe development <strong>of</strong> primary care practitioners <strong>with</strong> aninterest in gastroenterology and/or endoscopy has beena major advance during the last decade. Nationally,primary care specialists have been closely involved inthe production <strong>of</strong> guidelines by the National Institutefor Health and Care Excellence (NICE).5 Delivering a high-quality serviceCharacteristics <strong>of</strong> a high-quality serviceCare for <strong>patients</strong> <strong>with</strong> GI symptoms should be timely,evidence based, patient focused and consultant led.Although most patient care takes place in the outpatientdepartment, this should be supported ideally by acombined medical and surgical inpatient unit thatprovides senior-level expertise for the management <strong>of</strong>in<strong>patients</strong> <strong>with</strong> GI emergencies 7 days a week. Ahigh-quality service will: have properly timetabled audit and clinicalgovernance meetings fulfil the Joint Advisory Group (JAG) on GIEndoscopy’s requirements for endoscopy have sufficient time for staff development andappraisal100 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Gastroenterology and hepatology provide consultant input into clinical managementat a high level facilitate research and academic interests whereappropriate use evidence-based national and local guidelines onpatient management.<strong>Consultant</strong>s will also work closely <strong>with</strong> colleagues inother trusts to provide clinical networks to ensure that<strong>patients</strong> receive the highest quality <strong>of</strong> care. The BSG hasproduced a document on care standards for <strong>patients</strong><strong>with</strong> GI disorders 3 and recommendations onout-<strong>of</strong>-hours care. 4Resources required for a high-quality serviceSpecialised facilitiesSpecialised facilities are described clearly in the BSG’s<strong>working</strong> party report <strong>of</strong> 2001 (Provision <strong>of</strong>endoscopy-related services in district general hospitals) 5and in the RCP’s 2005 report. 6 Specialised facilitiesinclude: diagnostic and therapeutic endoscopy unit;facilities for parenteral nutrition; operative, anaestheticand intensive therapy unit (ITU) support;interventional radiology; and access to oncologyand tertiary referral units (eg regional livercentres).Adequate secretarial support for every consultant isessential. Communication is central to the safemanagement <strong>of</strong> <strong>patients</strong>, and good informationtechnology (IT) is necessary for auditing standards <strong>of</strong>practice <strong>with</strong>in the department. There should becomputer terminals at all workstations and inendoscopy rooms and <strong>of</strong>fices. In most gastroenterologydepartments, specialist nurses in endoscopy, cancer andpalliative care are fully integrated into the managementstructure.Quality standards and measures <strong>of</strong> the quality <strong>of</strong>specialist servicesSpecialist society guidelinesIn 2006, the BSG produced a quality standardsdocument backed up by data gathered over a 1-yearperiod. 3 This provides information on all aspects <strong>of</strong>gastroenterological practice and how this can beimproved. The BSG provides guidelines for the higheststandards <strong>of</strong> care in all areas <strong>of</strong> clinical practice ingastroenterology. These have been publishedby Gut and are available on the BSG’s website(www.bsg.org.uk).6 Clinical work <strong>of</strong> consultantsContribution to acute medicineAbout 60% <strong>of</strong> gastroenterologists participate inunselected medical take. They therefore commit a majorpart <strong>of</strong> their time to the management <strong>of</strong> <strong>patients</strong> <strong>with</strong>general medical problems as part <strong>of</strong> their unselectedacute medical take, ward work and outpatient work.The workload associated <strong>with</strong> acute medical take willincrease after the president <strong>of</strong> the RCP recommendedthat consultant <strong>physicians</strong> should be on site for 12-hourstretches each day at weekends and bank holidays whenon call.Many larger departments are adopting new models <strong>of</strong>service delivery to allow the consultant ‘on the wards’time to focus on the delivery <strong>of</strong> high-quality care toin<strong>patients</strong> which also includes responsibility for GIbleeding. Elective outpatient clinics and endoscopy listsare usually cancelled while ‘on the wards’ so that time isavailable for seeing inpatient referrals and emergencyprocedures, etc.Many consultant gastroenterologists act as trainers inboth the specialty and general medicine for foundationyear 1 and 2 trainees, core medical trainees and specialtyregistrars. Calculations suggest that the time taken totrain, appraise and complete the e-portfolio should be aminimum <strong>of</strong> 0.25 programmed activities (PAs) pertrainee.This section describes the work <strong>of</strong> a consultantphysician providing a service in acute general medicineand gastroenterology and recommends a workloadconsistent <strong>with</strong> high standards <strong>of</strong> patient care. It sets outthe work generated in gastroenterology by a 250,000population and gives the consultant workload as PA foreach element <strong>of</strong> such a service.The gastroenterology committee <strong>of</strong> the RCP and theBSG have published several studies concerned <strong>with</strong> theprovision <strong>of</strong> a combined general medical andgastroenterology service. The most recent summarisedthe nature and standards <strong>of</strong> gastrointestinal and liverservices in the UK. 3Working for <strong>patients</strong>A consultant-led team should look after no more than20–25 in<strong>patients</strong> at any time. Most <strong>patients</strong> areadmitted on emergency ‘take’ days <strong>with</strong> various generalmedical problems or are gastroenterologicalC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 101


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>emergencies triaged to the ward. A minority areadmitted, urgently or electively, for evaluation <strong>of</strong> GIproblems. PAs need to be allocated for at least threespecialist ward rounds per week and one post-take wardround per week per consultant, bearing in mind theRCP’s recommendations on the amount <strong>of</strong> time thatshould be devoted to each patient. 6Outpatient workNew patient clinicA consultant physician in gastroenterology <strong>working</strong>alone in a new patient clinic may see 6–8 new <strong>patients</strong> ina session, usually equivalent to one PA. The exactnumber <strong>of</strong> <strong>patients</strong> is dependent on experience and thecomplexity <strong>of</strong> the problem. Each new patient should begiven approximately 30 minutes.Follow-up clinicsA consultant physician <strong>working</strong> alone in a clinic forselected <strong>patients</strong> after acute medical orgastroenterological admission may see 12–15 <strong>patients</strong> ina session, usually equivalent to one PA. Each follow-upconsultation should be given about 15 minutes. Aphysician <strong>working</strong> alone in a specialist follow-up clinicfor chronic GI and liver disease sees 10–12 <strong>patients</strong> inone session. In practice, most gastroenterologists willrun clinics that involve a mixture <strong>of</strong> new and old<strong>patients</strong>.Support from junior medical staffOutpatient clinics are <strong>of</strong>ten run <strong>with</strong> doctors intraining; time must be allocated to review the <strong>patients</strong>seen by the trainees. The number <strong>of</strong> <strong>patients</strong> seen byjunior members <strong>of</strong> staff depends on their experience butin general the outpatient workload is increased by about50% <strong>of</strong> that undertaken by the consultant. It should benoted that this creates a potential saving only inoutpatient and endoscopy consultant sessions and notin the other components <strong>of</strong> the consultant’s work.Moreover, this saving (which amounts to perhaps onesession) is counterbalanced by the need for theconsultant to devote time to training (includingtraining in endoscopy). A specialist trainee should beable to see 4 new <strong>patients</strong> or 10 follow-up <strong>patients</strong> orsome combination <strong>of</strong> the two.Diagnostic and therapeutic endoscopyIt is essential that adequate time for training is allowedand that dedicated endoscopy training lists arescheduled into the programme. Training sessionsinevitably reduce the service throughput. Hands-ontraining cannot be carried out during a busy serviceendoscopy list.The workload <strong>of</strong> a consultant physician undertakingendoscopy depends on the procedure: Diagnostic upper gastrointestinal endoscopy:allowing 15–20 minutes per procedure, a maximum<strong>of</strong> 10–12 procedures should be carried out in asession equivalent to one PA. For a teaching session,6–10 <strong>patients</strong> should be allocated, <strong>with</strong> the numberdepending on the experience <strong>of</strong> the trainee. Diagnostic flexible sigmoidoscopy: a maximum <strong>of</strong>8–10 procedures should be carried out in a sessionequivalent to one PA. Therapeutic upper gastrointestinal endoscopy: thisincludes oesophageal or pyloric dilatation, treatment<strong>of</strong> bleeding ulcers, endoscopic resection <strong>of</strong> polyps orhigh-grade dysplasia in Barrett’s oesophagus,palliative treatment <strong>of</strong> oesophageal or gastric cancerand placement <strong>of</strong> feeding tubes (percutaneousendoscopic gastrostomy (PEG)). Such procedurestake two to three times as long as routine upper GIendoscopy and, allowing 30–40 minutes perprocedure, 5–6 might be undertaken in a session(4–5 for a teaching session). Therapeutic flexible sigmoidoscopy: this usuallyinvolves polypectomy and takes twice as long asroutine flexible sigmoidoscopy; 5–8 proceduresmight be undertaken in a session. Diagnostic and therapeutic colonoscopy: thereshould be a maximum <strong>of</strong> 6 colonoscopies persession (3–4 for a teaching session), allowing30–40 minutes per procedure. Diagnostic and therapeutic endoscopic retrogradecholangiopancreatography (ERCP): a maximum<strong>of</strong>4proceduresshouldbecarriedoutinonesession. Endoscopic ultrasound: 4–6 procedures should becarried out in one session but this will depend uponthe complexity (oesophagogastric or hepatic,pancreatic or biliary) and type (diagnostic ortherapeutic) <strong>of</strong> procedures. Video capsule endoscopy technology allowsdiagnostic views <strong>of</strong> the small intestine. Numbers <strong>of</strong>capsule studies read in a session depend on theexperience <strong>of</strong> the operator and the length <strong>of</strong> thestudy. Endoscopic tests <strong>of</strong> the small intestine (enteroscopy)are time-consuming because the small bowel is long102 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Gastroenterology and hepatology(up to 6 metres) and easily forms loops whenintubated. Passage may be assisted <strong>with</strong> balloons orspirals. These procedures are usually used to providetherapy to abnormalities found by capsule orradiological procedures. Numbers <strong>of</strong> tests in asession depend on the complexity <strong>of</strong> theprocedure.On call for GI emergenciesFor the safety <strong>of</strong> <strong>patients</strong>, it is necessary that NHSorganisations have formal and robust arrangementsto care for emergency <strong>patients</strong> presenting <strong>with</strong> upperGI bleeding, every day <strong>of</strong> the year, throughoutthe UK.The BSG have published documents on out-<strong>of</strong>-hourscare 4,7 calling for a reorganisation <strong>of</strong> services(‘hub-and-spoke’ model) to provide for safe care <strong>of</strong> allGI emergencies. In larger units (‘hub’) emergency covermay be available 24 hours a day, 7 days a week. On-callrotas should include all <strong>of</strong> those <strong>with</strong> appropriate skills,particularly members <strong>of</strong> the medical and surgical GIteams and interventional radiologists. 7 Even in thesmaller units (‘spoke’), as far as possible, the aimshould be to schedule sessions during the week and atweekends to manage <strong>patients</strong> admitted <strong>with</strong> acute GIbleeding.The BSG strongly endorse the need for 7-day care (notnecessarily 24 hours) for <strong>patients</strong> <strong>with</strong> acute severeupper GI bleeding and acute severe entero colitis andfor those <strong>with</strong> acute liver failure or acute cholangitis: anacute GI service is needed that covers all hospitals. Thiswould require a consultant gastroenterologist toundertake a ward round at weekends and on bankholidays in addition to standard care.Nutrition serviceNutrition teams responsible for enteral and parenteralfeeding services are usually led by consultant <strong>physicians</strong><strong>with</strong> an interest in gastroenterology. This should be<strong>with</strong>in the context <strong>of</strong> an MDT <strong>with</strong> core memberscomprising dietitians, nurses, pharmacist and clinician(usually a gastroenterologist). These teams haveexpertise in the promotion <strong>of</strong> adequate nutrition, egphysical help, protected mealtimes, nasogastric tube,PEG feeding or parenteral nutrition.Supervision <strong>of</strong> home-based parenteral nutrition for<strong>patients</strong> <strong>with</strong> type 2 or 3 intestinal failure is usuallyprovided from specialist centres. Nutritional roundsneed to be regular and would be expected to account for2 hours per week for the gastroenterologists who takeresponsibility for the nutritional service. Such roundswill <strong>of</strong>ten include critical care and surgical wards.All acute hospitals should have at least one nutritionnurse. 8Gastroenterologists are responsible for the placement <strong>of</strong>PEG tubes and are now required to be intimatelyinvolved in the pre-assessment <strong>of</strong> <strong>patients</strong> referred forthe procedure and in obtaining consent.HepatologyHepatology has developed as a subspecialty such thatmost gastroenterology units will require one or twohepatologists or at least someone who takes a lead rolefor liver disease, while transplant hepatology is deliveredin tertiary supra-regional units. Training in hepatologyhas been boosted by an extra sixth year specialtyhepatology training module. Alcoholic liver disease hasincreased the burden <strong>of</strong> acute hospital admissions, whilespecialist hepatitis B and C clinics are provided on anoutpatient basis. Hepatocellular cancer (HCC) isincreasing in incidence, and hepatologists areresponsible for surveillance <strong>of</strong> <strong>patients</strong> <strong>with</strong> cirrhosis,and <strong>of</strong>ten for discussions on treatment <strong>of</strong> HCC as part<strong>of</strong> MDT meetings.Academic medicineAcademic gastroenterologists are crucial for thedevelopment and implementation <strong>of</strong> new ideas aboutdisease pathogenesis and treatment. Clinical academics<strong>of</strong>ten provide specialist clinical services and tertiaryadvice related to their research activity and play acrucial role in training the future consultant body. Theclinical contribution <strong>of</strong> academic gastroenterologistsvaries widely depending on their other responsibilitiesand some academics may take on clinical leadershiproles <strong>with</strong>in the NHS. Most hold an honoraryconsultant contract <strong>with</strong> their local NHS trust, and theusual ratio <strong>of</strong> academic work to service work is 50:50,although wide variations and great flexibility exist inpractice. The academic gastroenterologist would beexpected to provide proportional input into thegastroenterology service according to the nature <strong>of</strong> thecontract and the job plan which should be agreed byuniversity and NHS as part <strong>of</strong> the joint appraisalprocess. It should be stressed that this will beproportionate for all activities in a gastroenterologist’sjob description, including support, training,governance, teaching (<strong>of</strong>ten undertaken duringC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 103


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>academic part <strong>of</strong> job plan) and administrative roles, aswell as direct patient-related activities.7 Opportunities for integrated careA more fluid relationship between primary andsecondary care is developing, eg Choose and Bookguidance and advice. There are opportunities for GPs todevelop special interests and to work <strong>with</strong>in GP clustersto advise on referrals to secondary care and to undertakespecialist clinics in the community. Future management<strong>of</strong> chronic conditions such as irritable bowel syndrome(IBS), dyspepsia and coeliac disease will need to involveintegrated care to decrease referrals to secondary care.By collating activities such as referral management, use<strong>of</strong> Choose and Book (guidance/advice), clinicalassessment services, telephone helplines, GP educationand feedback for improvements in integrated care maybe achievable. Shared care protocols for monitoring <strong>of</strong>drugs such as thiopurines are required to facilitate safefollow-up in the community.Diagnostic endoscopic procedures such as flexiblesigmoidoscopy may be undertaken in communityhospitals but the JAG standards will make this a lessattractive option.8 Workforce requirements for the specialtyCurrent workforce numbersOn 30 September 2012, there were 1,005 consultantgastroenterologists in England. A whole-timeconsultant currently serves a population <strong>of</strong> around51,000; however, there is considerable variation.Presently, 15% <strong>of</strong> consultants are women and only 14%<strong>of</strong> consultants work part time (receive


2 Specialties Gastroenterology and hepatologyprocedure annually. Half <strong>of</strong> these are likely to beperformed by GI <strong>physicians</strong>. Nine PAs per week arerequired for these procedures, allowing for trainingrequirements. Endoscopic ultrasound scanning (EUS) and ERCP:these are currently performed at an annual incidence<strong>of</strong> 0.2%, <strong>with</strong> little change anticipated. Four PAs areneeded for ERCP and EUS, assuming that 80% <strong>of</strong>these are performed by GI <strong>physicians</strong>. Cancer screening and surveillance programmes:there is a national bowel cancer screeningprogramme needing approximately two lists perweek <strong>of</strong> colonoscopy, rising to three lists per week<strong>with</strong> full age and regional roll-out, and anincreasing surveillance burden generated frominvestigating and treating these <strong>patients</strong>.Approximately 2 (rising to 3) PAs are required forthis activity.Out-<strong>of</strong>-hours GI serviceAn out-<strong>of</strong>-hours (OOH) GI service may include anemergency therapeutic endoscopy service alone or7-day cover for <strong>patients</strong> <strong>with</strong> acute GI emergencies. Thecost implications <strong>of</strong> the OOH endoscopy service willdepend on the nature <strong>of</strong> the service (24 hours ordaytime cover only) and the number <strong>of</strong> consultants onthe rota but is likely to cost at least one consultant PAper week. Weekend and bank holiday cover forin<strong>patients</strong> would cost about 1 PA (3 hours <strong>of</strong> premiumtime) for each day covered.Nutrition serviceThis service requires up to two consultant PAs perweek.<strong>Consultant</strong> programmed activities required toprovide a service in gastroenterology and generalinternal medicine in a DGHDirect patient careWhere members <strong>of</strong> the junior medical staff providesupport for the inpatient service and consultantsprovide the outpatient and endoscopic service, about54PAsperweekarerequiredtoprovideaserviceinaDGH <strong>with</strong> an average workload. The number <strong>of</strong> PAsrequired to run the service is reduced if part <strong>of</strong> the workis undertaken by consultant colleagues – eg those inradiology or surgery might share the endoscopicworkload over and above that assumed in thecalculations above. It has been assumed that half <strong>of</strong> allupper and lower GI endoscopic procedures will beperformed by non-GI <strong>physicians</strong> – either otherconsultants or nurse specialists. Regular help inout<strong>patients</strong> may come from junior medical staff – each<strong>of</strong> whom might contribute to the work done by around50% <strong>of</strong> that recommended for a consultant PA. Itshould be noted that the delivery <strong>of</strong> an endoscopytraining list is counted as a direct clinical caresession.Work to maintain and improve the quality<strong>of</strong> careAdditional PAs for each consultant are required for thiswork. This has been estimated at up to 2.5 PAs perconsultant, using the RCP’s guidelines, and includes:continuing pr<strong>of</strong>essional development (CPD); teaching<strong>of</strong> junior medical staff, nursing staff and medicalstudents; administration and management; clinicalresearch; and clinical governance.On the basis <strong>of</strong> these conditions and recommendations,the number <strong>of</strong> PAs needed to provide a clinical servicein gastroenterology and general medicine for a DGHserving a 250,000 population can be calculated.Allowing 2.5 PAs for each consultant for thesupporting activities (SPAs) given above, the total is 69PAs (this assumes 6 consultants all <strong>working</strong> 11.5 PAs perweek).Table 1 summarises the work programme <strong>of</strong> consultantgastroenterologists providing a service for a 250,000population, giving the recommended workload andallocation <strong>of</strong> PAs (see page 106).National consultant workforce requirementThe calculation allows an estimate <strong>of</strong> the nationalconsultant requirement to be made. Assuming thepopulation <strong>of</strong> England and Wales is 53,861,800 (DHfigures for 2008), the total need in England and Wales is1,753 head count consultants in gastroenterology (<strong>with</strong>general medicine), using the Centre for WorkforceIntelligence calculations.9 <strong>Consultant</strong> work programme/specimenjob planTable 2 summarises an example <strong>of</strong> the work programme<strong>of</strong> consultant <strong>physicians</strong> undertaking gastroenterologyand acute general medicine, giving the recommendedworkload and allocation <strong>of</strong> PAs.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 105


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Work undertaken by consultant gastroenterologists (total PAs per week) serving a population <strong>of</strong> 250,000Activity Workload Programmed activities (PAs)Direct patient careWard rounds (except on-take and post-take) 3Outpatient clinicsNew <strong>patients</strong> 6–8 <strong>patients</strong> per clinic 9Follow-up <strong>patients</strong> 12–15 <strong>patients</strong> per clinic 13Diagnostic and therapeutic endoscopyDiagnostic and therapeutic upper GI endoscopy (10–12 <strong>patients</strong> per PA) 3Diagnostic flexible sigmoidoscopy (10–12 <strong>patients</strong> per clinic) 3Diagnostic and therapeutic colonoscopy (6 <strong>patients</strong> per clinic) 6EUS and ERCP (5 <strong>patients</strong> per clinic) 4Nutrition service 2On-take, and mandatory post-take rounds Rota 1:10 for this example 1MDT meetings 3Additional direct clinical care 6On call for emergency endoscopy(assuming some registrar input to the rota) 1Total direct patient care 54Work to maintain and improve the quality <strong>of</strong> care (6 consultants) 15Total 6910 Key points for commissionersA good-quality service for gastroenterology andhepatology should include: 91 an endoscopy service that participates in the GlobalRating System, is accredited by the JAG, participatesin national audit, provides/participates in a networkthat provides 24-hour/7-day endoscopy service forgastrointestinal bleeding and ensures that all<strong>patients</strong> over 40 <strong>with</strong> recent onset rectal bleedingand/or persistent diarrhoea >3 weeks have access t<strong>of</strong>lexible sigmoidoscopy or colonoscopy <strong>with</strong>in 4weeks. Efficient use <strong>of</strong> facilities should usuallyinclude evening and weekend lists. Commissionersshould negotiate <strong>with</strong> trusts to achieve a transparentshift <strong>of</strong> activity from unnecessary endoscopy inyoung <strong>patients</strong> <strong>with</strong> dyspepsia towards appropriatelyincreased resources to meet appropriately increaseddemand for lower-GI endoscopy2 an inflammatory bowel disease service that isseparately commissioned, conforms to the IBDStandards (www.ibdstandards.org.uk)andparticipates in national clinical audit3 a hepatology service that is separately commissionedand that ensures appropriate monitoring <strong>of</strong> <strong>patients</strong><strong>with</strong> chronic liver disease for prophylactic treatment<strong>of</strong> varices and early diagnosis <strong>of</strong> hepatocellularcarcinoma, and that includes 7 days/weekavailability <strong>of</strong> appropriately trained specialist carefor <strong>patients</strong> <strong>with</strong> acute jaundice and liver failure. Theservice should be provided by an appropriate MDTas defined in the National Liver Plan(www.bsg.org.uk/attachments/1004 National%20Liver%20Plan%202009.pdf)4 provision <strong>of</strong> a consultant gastroenterology/hepatology ward round on each day includingweekends and public holidays5 a multidisciplinary alcohol care team, integratedacross primary and secondary care but <strong>with</strong> ahospital base, providing a 7 days/weekservice to support <strong>patients</strong> <strong>with</strong> alcohol-relatedproblems, improve abstinence, and reducere-admission rates6 efficient use <strong>of</strong> outpatient services <strong>with</strong> lowfollow-up to new ratios, eg 1:1 for <strong>patients</strong> excludingthose <strong>with</strong> chronic disease (IBD and liver disease)and appropriate use <strong>of</strong> nurse-led clinics, telephone106 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Gastroenterology and hepatologyTable 2 Example work programme <strong>of</strong> consultant <strong>physicians</strong> undertaking gastroenterologyActivity Workload Programmed activities (PAs)Direct clinical careOn-take and mandatory post-take rounds (According to numbers <strong>of</strong> admissions, rota and 1–4non-consultant support)It is recommended that all other activities arecancelled for a large proportion <strong>of</strong> the time when aconsultant is on-take for acute medicine, which willclearly have an impact on the routine clinicalworkload that can be undertaken by a consultant.Oncall for emergency endoscopy 0–1Ward rounds and other inpatient work2(except post-take rounds – see above)Referrals and specialist services (eg1nutrition rounds, monitoring service)Diagnostic and therapeutic endoscopy ∗ Diagnostic upper GI endoscopy: 10–12 †1–2Diagnostic and therapeutic ERCP: 4 †Therapeutic upper GI endoscopy: 5–6 †Diagnostic flexible sigmoidoscopy: 10–12 †Diagnostic and therapeutic colonoscopy: 6 †Out<strong>patients</strong> (general medical or specialist) New: 6–8 <strong>patients</strong> per clinic1–2Follow-up: 12–15 <strong>patients</strong> per clinicClinically related administration 1.5–2.5Total number <strong>of</strong> direct clinical care PAs7.5 on averageSupporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality<strong>of</strong> healthcareOther NHS responsibilitiesExternal dutiesEducation and training, appraisal, departmentalmanagement and service development, audit andclinical governance, CPD and revalidation, researcheg medical director, clinical director, lead consultantin specialty, clinical tutoreg work for deaneries, royal colleges, specialistsocieties, DH or other government bodies, etc2.5 on averageLocal agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trust∗ List sizes will be reduced proportionately if training is included.† Numbers = <strong>patients</strong> per 4-hour list.and email consultation. Efficient first consultationfor new <strong>patients</strong> should be facilitated by the use <strong>of</strong>structured referral forms containing relevant dataand pre-investigation results, agreed by localconsultation between primary and secondary care.Secondary-care trusts should provide explicitinformation that allows targeted referral <strong>of</strong><strong>patients</strong> to the most appropriate subspecialtyservice7 a multidisciplinary nutrition service that providesdaily input into the care <strong>of</strong> in<strong>patients</strong> <strong>with</strong>nutritional problems, and provides specialist dieteticsupport in all settings for <strong>patients</strong> <strong>with</strong> specialdietary requirements including <strong>patients</strong> <strong>with</strong> liverdisease, IBD, coeliac disease and <strong>patients</strong> <strong>with</strong> shortbowel. A coeliac disease service conforming to NICE(www.nice.org.uk/CG86) and European Society forPaediatric Gastroenterology, Hepatology andNutrition (www.espghan.med.up.pt) standards ondiagnosis, national guidance on management andusing cost-efficient pharmacy supply schemes tomanage prescriptions.See also Table 3.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 107


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Audit Patient questionnairesTable 3 Commissioning gastroenterology services and measuring qualityEffectiveness Safety Patient experienceIrritable bowel syndrome NICE CG61 (2008); 10BSG guideline (2007) 11Iron-deficiency anaemia BSG guideline (2011) 12 Audit QuestionnaireNutrition NICE CG32 (2006) 8 NCEPOD report 2010 AuditCoeliac disease NICE CG86 (2009) 13 Audit Patient questionnairesDyspepsia NICE CG17 (2004) 14 AuditInflammatory bowel diseaseNational standards for IBD Care(2009); 15 BSG guideline (2011); 16NICE TA187 biologics (2010); 17NICE CG118 (2011) 18Results <strong>of</strong> National IBDAuditAssessed by auditResults <strong>of</strong> National UGIBAcute upper GI bleeding Scope for improvement (2011); 7141 (2012) 20BSG guideline (2009); 19 NICE CG auditQuestionnaireAlcohol-related diseaseBSG guideline (2010); 21 NICE CG Audit <strong>of</strong> alcohol-related115 (2011) 22 (re)admissions and deathSurvival <strong>with</strong>out alcoholEndoscopy services BSG QA/Global Rating Scale 23 BSG QA/Global RatingScale; JAG approvalGlobal Rating Scale scoresA/B; patient questionnairesReferences1 Department <strong>of</strong> Health. Clinical outcomes guidelines.London: DH, 2000.2 National Confidential Enquiry into Patient Outcome andDeath. Parenteral nutrition: a mixed bag. London:NCEPOD, 2010.3 British Society <strong>of</strong> Gastroenterology. Care <strong>of</strong> <strong>patients</strong> <strong>with</strong>gastrointestinal disorders in the United Kingdom, a strategyfor the future. London: BSG, 2006.4 Barrison IG. Out <strong>of</strong> hours gastroenterology. Apositionpaper. London: BSG, 2007.5 Barrison IG, Bramble M, Wilkinson M et al. Provision <strong>of</strong>endoscopy related services in district general hospitals.London: BSG, 2001.6 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. <strong>Consultant</strong> <strong>physicians</strong><strong>working</strong> <strong>with</strong> <strong>patients</strong>, 3rd edn. London: RCP,2005.7 British Society <strong>of</strong> Gastroenterology. Scope forimprovement: a toolkit for a safer upper gastrointestinalbleeding (UGIB) service. London: BSG, 2011.8 National Institute for Health and Care Excellence.Nutritional support in adults: oral nutrition support,enteral feeding and parenteral nutrition. Clinical guidelineCG32. London: NICE, 2006.9 British Society <strong>of</strong> Gastroenterology. Commissioningevidence-based care for <strong>patients</strong> <strong>with</strong> gastrointestinal andliver disease. London: BSG, 2012.10 National Institute for Health and Care Excellence.Irritable bowel syndrome in adults: diagnosis andmanagement <strong>of</strong> irritable bowel syndrome in primary care.Clinical guideline CG61. London: NICE, 2008.11 British Society <strong>of</strong> Gastroenterology. Guidelines on theirritable bowel syndrome: mechanisms and practicalmanagement. London: BSG, 2007.12 Goddard AF, James MW, McIntyre AS, Scott BB.Guidelines for the management <strong>of</strong> iron deficiencyanaemia. Gut 2011;doi 10.1136/gut.2010. 228874.13 National Institute for Health and Care Excellence.Recognition and assessment <strong>of</strong> coeliac disease. Clinicalguideline CG86. London: NICE, 2009.14 National Institute for Health and Care Excellence.Managing dyspepsia in adults in primary care. Clinicalguideline CG17. London: NICE, 2004.15 IBD Standards Group. Quality care: service standards forthehealthcare<strong>of</strong>peoplewhohaveinflammatoryboweldisease (IBD). Brighton: Oyster HealthcareCommunications, 2009.16 Carter MJ, Lobo AJ, Travis SPL. Guidelines for themanagement <strong>of</strong> inflammatory bowel disease in adults.Gut 2004;53(Suppl 5):v1–v16.17 National Institute for Health and Care Excellence.Crohn’s disease - infliximab (review) and adalimumab(review <strong>of</strong> TA40): guidance. Technology appraisal TA187.London: NICE, 2010.108 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Gastroenterology and hepatology18 National Institute for Health and Care Excellence.Colonoscopic surveillance for prevention <strong>of</strong> colorectalcancer in people <strong>with</strong> ulcerative colitis, Crohn’s disease oradenomas. Clinical guideline CG118. London: NICE,2011.19 British Society <strong>of</strong> Gastroenterology. Guidelines fornon-variceal upper gastrointestinal haemorrhage. London:BSG, 2010.20 National Institute for Health and Care Excellence. Acuteupper gastrointestinal bleeding. Clinical guideline CG 141.London: NICE, 2012.21 British Society <strong>of</strong> Gastroenterology. Alcohol-relateddisease: meeting the challenge <strong>of</strong> improved quality<strong>of</strong> care and better use <strong>of</strong> resources. London: BSG,2010.22 National Institute for Health and Care Excellence. Alcoholdependence and harmful alcohol use. Clinical guidelineCG 115. London: NICE, 2011.23 British Society <strong>of</strong> Gastroenterology. Global rating scale.www.grs.nhs.ukC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 109


2 Specialties Genitourinary medicineGenitourinary medicineDr Jackie Sherrard FRCP <strong>Consultant</strong> genitourinary physician1 Description <strong>of</strong> the specialtyGenitourinary medicine (GUM) is the medical specialtyconcerned <strong>with</strong> the screening, diagnosis and management<strong>of</strong> sexually transmitted infections (STIs) and relatedgenital medical conditions. In the past 30 years, thescope <strong>of</strong> clinical work has broadened to include humanimmunodeficiency virus (HIV) diagnosis and acquiredimmune deficiency syndrome (AIDS) management.STIs, including HIV, are currently <strong>of</strong> major public healthconcern. This has been recognised by the Department<strong>of</strong> Health (DH) and 48-hour access to GUM serviceswas an NHS priority in England from 2008 to 2011.A distinctive feature and strength <strong>of</strong> GUM clinics is theholistic approach whereby STIs and HIV diagnosis andmanagement, contraceptive advice/emergencycontraception, health promotion/risk reduction adviceand partner notification, are all provided in the sameclinic. However new commissioning arrangements fromApril 2013 mean GUM services including HIVprevention and diagnoses will be commissioned by localauthorities and HIV management by the NationalCommissioning Board. It is hoped that this split will notlead to fragmentation <strong>of</strong> care.The British Association for Sexual Health and HIV(BASHH) is the GUM national specialist society and isaffiliated <strong>with</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP). Itprovides the specialty <strong>with</strong> a framework for education,clinical governance and audit.Who are the <strong>patients</strong>?GUM is primarily outpatient based. The largest group<strong>of</strong> <strong>patients</strong> are those <strong>with</strong> STIs and a range <strong>of</strong> othersexual health conditions. Much activity is related tosexual health advice-seeking and screening which formsan important part <strong>of</strong> the prevention and public healthrole <strong>of</strong> the specialty. STIs affect all sections <strong>of</strong> thepopulation; however, case finding by screening at-riskgroups and the identification <strong>of</strong> sexual partners <strong>of</strong>persons <strong>with</strong> STIs are necessary components to controlthe spread <strong>of</strong> infection. Approximately 50% <strong>of</strong> <strong>patients</strong>are under 25 years <strong>of</strong> age. The service sees adisproportionate number <strong>of</strong> vulnerable people, egyoung people, immigrants, drug users, commercial sexworkers and <strong>of</strong>fenders.Main disease patternsThe impact <strong>of</strong> poor sexual health is greatest in youngadults and in men who have sex <strong>with</strong> men (MSM). Overthe past 10 years, increased transmission through unsafesexual behaviour, especially among MSM, hascontributed to a substantial increase in STI diagnoses.Untreated STIs can lead to serious costly sequelae.Management <strong>of</strong> STIs is important in the control <strong>of</strong> HIVinfection because evidence indicates that STIspredispose to the transmission <strong>of</strong> HIV.Patients <strong>with</strong> HIV infection form a rapidly increasingand time-consuming group <strong>with</strong> a wide variety <strong>of</strong>medical, social and other problems. Newly diagnosedHIV infections continue to increase. Highly activeantiretroviral therapy (HAART) has improved survival,further adding to caseloads.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceHistorically, clinics provided an open access walk-infacility. Recently, higher numbers <strong>of</strong> <strong>patients</strong> and limitedresources have led to increased use <strong>of</strong> appointmentsystems. Patients attend the clinic <strong>of</strong> their choice – thismay or may not be near where they live or work because<strong>of</strong> travel or concerns about confidentiality. Sevices are<strong>working</strong> increasingly <strong>with</strong> contraceptive services todeliver more integrated sexual health services.Sources <strong>of</strong> referralMost <strong>patients</strong> self-refer but a proportion are referredfrom general practice, family planning, accident andemergency (A&E) departments and other providers.Locality-based and/or regional servicesSpecialist services in GUM provide primary level STImanagement, particularly in urban areas and to those<strong>with</strong>out easy access to health services. They also providesecondary and tertiary level referral and referenceC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 111


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>services to other providers and training for healthcareworkers. These functions require accessible, confidentialservices staffed by appropriately trained multidisciplinaryteams.Secondary careGUM specialists provide a service for the community indesignated departments. There should be facilities forout<strong>patients</strong>, and any service <strong>with</strong> HIV-infected <strong>patients</strong>should have access to day care and beds. Althoughconsultants work primarily in outpatient clinics, theyare on call for urgent problems and provide support forother specialists. It is essential that single-handedconsultants have regular meetings <strong>with</strong> GUM colleaguesfor audit and continuing pr<strong>of</strong>essional development(CPD). GUM services are usually key stakeholders inthe local chlamydia screening service.Tertiary careExamples <strong>of</strong> conditions managed in tertiary careinclude complex HIV disease, sexual problems andvulval disorders.Community models <strong>of</strong> careWhile historically GUM clinics were based in acutehospital sites, an increasing number are now provided<strong>with</strong>in community settings. Some services areco-located <strong>with</strong> other sexual health providers or provideintegrated services to variable degrees. The DH’snational sexual health strategy for England and Walesoutlined the increasing role that primary care isexpected to take in screening for STIs. 1 The strategy setstandards for those providing care at this level andGUM collaborates in developing protocols, training andclinical governance. There is evidence in primary careservices <strong>of</strong> both increased screening for Chlamydiatrachomatis and referral to GUM clinics.Complementary servicesComplementary medicine services are valued by<strong>patients</strong> <strong>with</strong> HIV and are usually supplied by voluntaryservices.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong>Involving <strong>patients</strong> in decisions abouttheir treatmentIt is essential that <strong>patients</strong> are involved in treatmentdecisions, especially for successful antiretroviraltherapy where it has been shown that thedoctor–patient relationship and understanding <strong>of</strong>treatment are key components for the long-termadherence and success <strong>of</strong> therapy. To preventonward transmission <strong>of</strong> STIs, <strong>patients</strong> need aclear understanding <strong>of</strong> the aims <strong>of</strong> therapy andthe importance <strong>of</strong> partner notification.The specialty sets great store by theseprinciples.Patient choice: ethnic and religiousconsiderationsCultural sensitivity is essential in sexual health.Information for <strong>patients</strong> is published in manylanguages. Intimate examinations need to be carefullyexplained and understood by <strong>patients</strong>, especially thosewho may have cultural taboos in respect <strong>of</strong> femaleexamination. Patients <strong>with</strong> HIV from developingcountries will <strong>of</strong>ten have beliefs in traditional medicineor disease causation that need to be addressed.Sensitivity to <strong>patients</strong>’ sexual orientation is an integralpart <strong>of</strong> care.Opportunities for education and promotingself careEducation is a cornerstone <strong>of</strong> GUM for the prevention<strong>of</strong> transmission <strong>of</strong> infection. Verbal explanations andwritten materials are provided for all <strong>patients</strong> <strong>with</strong>STIs/HIV during consultations. Health advisers providean extra level <strong>of</strong> education for those <strong>with</strong> serious orrecurrent disease, eg syphilis, gonorrhoea and HIV.Emphasis is placed on prevention (using condoms,number <strong>of</strong> sexual partners, healthcare-seekingbehaviour). The relatively low incidence <strong>of</strong> HIV in theUK has been partly attributed to these interventions.MSM are routinely advised to have hepatitis Bvaccination.Patients <strong>with</strong> chronic conditionsThe main groups are <strong>patients</strong> <strong>with</strong> HIV, hepatitis B andC, recurrent herpes, warts and the sequelae <strong>of</strong> pelvicinflammatory disease. Many <strong>patients</strong> opt for continuingcare in GUM. Psychological services are required but areunderprovided in the majority <strong>of</strong> clinics.The role <strong>of</strong> the carerApartnersittinginontheconsultationcanhelptoensure that information and advice are understood, aslong as issues <strong>of</strong> confidentiality are considered. Carersfrequently accompany <strong>patients</strong> <strong>with</strong> HIV disease andcan be vital to adherence to HAART.112 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Genitourinary medicineAccess to information, patient support groupsand the role <strong>of</strong> expert patientInformation on STIs and other areas <strong>of</strong> sexual health isfreely available through written material and clinicalstaff. Many clinics have websites providing clinicinformation and general information on STIs.Patient support groups and expert <strong>patients</strong> have been along established and valuable feature <strong>of</strong> HIV care, but,in the field <strong>of</strong> STIs, similar support groups and expert<strong>patients</strong> are notable by their rarity and should beencouraged. BASHH has establised a public panel and isproducing patient information leaflets through itsclinical effectiveness group. The Herpes Association andthe Vulval Pain Society provide sources <strong>of</strong> support andinformation.Availability <strong>of</strong> clinical records/resultsClinics increasingly provide results by text, email or24-hour telephone lines. GUM outpatient records andcomputer registration are kept separate from generalhospital records for reasons <strong>of</strong> confidentiality. Access totest results is increasingly linked to service laboratoriesby computer. Tests should be anonymised by codedidentifiers. These systems should be ‘firewalled’ fromusers outside the clinic and laboratories. Access to notesby <strong>patients</strong> or for medicolegal reasons is as for otherspecialties.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>Multidisciplinary work is key to quality service delivery.Nurse-led clinics and nurse practitioners areincreasingly frequent. Health advisers are an importantpart <strong>of</strong> teams. Close links <strong>with</strong> microbiologists andvirologists are essential.Many HIV services hold regular multidisciplinary teammeetings which have an important training role.Working <strong>with</strong> other specialistsMost <strong>patients</strong> <strong>with</strong> STIs and allied conditions aremanaged <strong>with</strong>in the clinics. Relationships <strong>with</strong> otherservices include obstetrics and gynaecology, urology,pathology, family planning and psychology. Close links<strong>with</strong> the Health Protection Agency (HPA) have beenforgedoverrecentyearsandhaveyieldedbenefitsinepidemiological surveillance and the targeting <strong>of</strong> healthpromotion.HIV <strong>patients</strong> require integrated care and collaborationbetween primary and secondary care and communityhealth services. National standards have recommendedthe development <strong>of</strong> clinical networks to manage HIVinfection. 2Working <strong>with</strong> GPs and GPs <strong>with</strong> a specialinterest (GPwSIs)Sexual health has been identified as a priority for thedevelopment <strong>of</strong> GPwSIs. GUM has many GPs who dosessional work and are ideally placed to take onenhanced roles in primary care. The specialty iscommitted to <strong>working</strong> closely <strong>with</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong>General Practitioners (RCGP) and commissioningorganisations to provide training programmes andclinical governance for these GPs.Other specialty activity beyond local servicesMany services have set up outreach clinics includingprimary healthcare settings and prisons. Mostconsultants take a leading role in local sexual health andHIV clinical networks.5 Delivering a high-quality serviceStandards that cover all aspects <strong>of</strong> management <strong>of</strong> STIs,including the diagnosis and treatment <strong>of</strong> individualsand the public health role <strong>of</strong> infection control, werepublished by BASHH in 2010. 3Characteristics <strong>of</strong> a high-quality serviceFor STIs All <strong>patients</strong> should be <strong>of</strong>fered an appointment<strong>with</strong>in 48 hours <strong>of</strong> contacting the service. Patients <strong>with</strong> a suspected acute STI should be seenon the day that they present. Clinics should be in good quality, easily accessiblepremises. Interviewing rooms and examinationrooms should afford privacy. 4 Management includes taking a general and sexualhistory, a physical examination and collection <strong>of</strong>appropriate specimens. Patients should be <strong>of</strong>fered achaperone in line <strong>with</strong> General Medical Council(GMC) guidance. Clinical examination is supported by immediatemicroscopy <strong>of</strong> samples, requiring staff to be trainedand monitored in their practice <strong>of</strong> microscopy. Patients <strong>of</strong>ten have multiple infections. STIs may beasymptomatic, and for that reason <strong>patients</strong> are<strong>of</strong>fered screening for other common conditions.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 113


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> Provision <strong>of</strong> free treatment for STIs is a legalrequirement. Patients <strong>with</strong> STIs are advised on the need to notifysexual partners at risk <strong>of</strong> infection and <strong>of</strong>feredcounselling on sexual health in general. They are<strong>of</strong>fered leaflets to support verbal information andfree condoms. Most clinics provide generalcontraceptive advice; some provide emergency androutine contraception methods. Follow-up appointments are required to assessresolution <strong>of</strong> symptoms and compliance <strong>with</strong>medication, to undertake tests <strong>of</strong> cure, to ensure thatpartners have been notified and to <strong>of</strong>fer furthersexual health advice if required. Enhanced confidentiality for all <strong>patients</strong> is set out instatute and must be guaranteed by all members <strong>of</strong>staff. All <strong>patients</strong> presenting to GUM clinics are <strong>of</strong>feredscreening for HIV infection.For HIV infection Standards for NHS HIV services recommend theestablishment <strong>of</strong> clinical networks. At the first visit, a full history is taken and a physicalexamination, including STI screen, is performed.Investigations include viral load and CD4lymphocytes, and those for clinical or laboratoryevidence <strong>of</strong> current or past comorbidity. Patients require regular monitoring <strong>of</strong>immunological and virological parameters andcommencement on HAART as needed. When complications occur, outpatient or inpatientcare <strong>with</strong> appropriate staff and facilities forinvestigations and management are required. Longer appointment times are required for HIV<strong>patients</strong> than those <strong>with</strong> STI.Maintaining and improving the quality <strong>of</strong> careLeadership role and development <strong>of</strong> the serviceRecent strategy documents have emphasised the needfor more community-based care, and that standardsshould be set for this. Any service development musttake into account the individual, and the impact onpublic health. The enhanced awareness and anticipatedcase finding will increase patient attendance at clinics.Adequate resources are the main requirement forimproved patient care.The principal aim is for <strong>patients</strong> suspecting an STI to beseen on the day that they present or when the clinic isnext open. It is to be determined whether this is bestprovided by open access or a flexible appointmentsystem. Evening and weekend <strong>working</strong> depends onadequate resources and contractual agreement. Staffskill mix and multidisciplinary <strong>working</strong> requiresconsideration but an overall increase in workforce isnecessary to increase capacity.Improved laboratory diagnosis, such as nucleic acidamplification tests, are under continualimplementation. Implicit in these developments is theneed to produce timely reports, entailing cooperation<strong>with</strong>in trusts between laboratories and clinics, and morewidely between the HPA and trusts.Services should have agreed written guidance for allaspects <strong>of</strong> management to improve and maintainquality and maximise risk avoidance andmanagement.Education and trainingMost teaching is carried out by NHS consultants inoutpatient clinics and on undergraduate andpostgraduate courses. The paucity <strong>of</strong> teaching time inGUM in most undergraduate courses is <strong>of</strong> concern.More academic posts would enhance the capacity forteaching. With the development and delivery <strong>of</strong> STIfoundation courses, BASHH has a critical function inthe delivery <strong>of</strong> sexual health education tonon-specialists.Mentoring and appraisal <strong>of</strong> medical and otherpr<strong>of</strong>essional staff<strong>Consultant</strong>s should be regarded as the team leader forclinical matters for medical, nursing and health advisingstaff <strong>of</strong> all grades. All staff should have annual appraisaland personal development planning.Continuing pr<strong>of</strong>essional developmentSpecialist GUM providers play a key role in supportingthe delivery <strong>of</strong> education, training and governanceacross the range <strong>of</strong> providers <strong>with</strong>in a sexual healtheconomy and as such maintenance <strong>of</strong> CPD is essential.This is supported by BASHH scientific and CPDmeetings, regionally and nationally throughoutthe year.Clinical governanceGUM services are central to local networks <strong>of</strong> STIservice providers, and essential for setting the clinicalgovernance framework, for care pathways and forproviding training to other services in the network.114 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Genitourinary medicineClinical governance is overseen by BASHH’s clinicalgovernance committee.ResearchThe establishment <strong>of</strong> special interest groups in GUM byBASHH has promoted the research agenda <strong>of</strong> thespecialty. In HIV medicine, academic posts have beencritical to clinical and basic research. Continued clinicaland scientific research into STIs and HIV is essentialand many clinics work closely <strong>with</strong> the MedicalResearch Council (MRC), industry and other partners.Local management dutiesEach GUM service providing diagnostic and therapeuticservices for STI and HIV should be led by those holdinga Certificate <strong>of</strong> Completion <strong>of</strong> Training (CCT), orequivalent, in GUM. As a multidisciplinary team, theday-to-day management leadership should devolve to alead GUM consultant; he or she would have amanagerial relationship to the general managementstructure <strong>of</strong> the provider trust.Regional and national workMany GUM specialists participate in regional andnational work, for the RCP, BASHH and local deaneries,in addition to <strong>working</strong> closely <strong>with</strong> agencies such as theHPA on public health matters.Specialty and national guidelinesSpecialist guidelines for STIs were first published in1999. The updated guidelines include other areas <strong>of</strong>practice and are available at www.bashh.org. 5Guidelines for HIV management and treatment arepublished by the British HIV Association (BHIVA).The National Institute for Health and Care Excellence(NICE) guidelines include: public health intervention guidance on theprevention <strong>of</strong> sexually transmitted infections andreduction <strong>of</strong> under-18 conceptions generic and specific interventions to supportattitude and behaviour change at population andcommunity levels increasing the uptake <strong>of</strong> HIV testing to reduceundiagnosed infection and prevent transmissionamong black African communities living in England(NICE 2011) increasing the uptake <strong>of</strong> HIV testing among menwho have sex <strong>with</strong> men (NICE 2011).Specialty and national audit<strong>Consultant</strong>s review the notes <strong>of</strong> <strong>patients</strong> to monitorquality <strong>of</strong> care and ensure that accurate diagnoses areentered on workload and epidemiological returns madeto trusts and the HPA on behalf <strong>of</strong> the DH.In 2003, BASHH established a national audit groupwhich undertakes an annual national audit. Specialtyspecificstandards have been developed and arerecommended as an integral part <strong>of</strong> the revalidationprocess. There are national HIV audits through BASHHand BHIVA programmes.The British Co-operative Clinical Group, a specialinterest group <strong>of</strong> BASHH, conducts regular nationalsurveys and publishes the results <strong>of</strong> clinic practices.6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialtyInpatient workThe GUM service may require inpatient accessfor the management <strong>of</strong> complex infections (such asHIV-related complications). A range <strong>of</strong> in<strong>patients</strong>pecialties may require access to clinical opinion fromGUM consultants, who should be available to giveopinion to colleagues on request. GUM <strong>physicians</strong> whoact as sole consultant for in<strong>patients</strong> should have currentknowledge <strong>of</strong> HIV/AIDS medicine to an acceptablelevel. Levels <strong>of</strong> junior medical staffing should besufficient to support GUM admissions.Ward rounds vary according to the numbers <strong>of</strong> <strong>patients</strong>.Many district general hospitals (DGHs) have only oneor two GUM/HIV in<strong>patients</strong> at any one time.<strong>Consultant</strong>s in DGHs may be single-handed <strong>with</strong>minimal supporting staff and manage most/all <strong>of</strong> thecare themselves. Alternatively, inpatient care may beshared <strong>with</strong> colleagues in other disciplines such asinfection or thoracic medicine. Larger units have severalGUM consultants, some <strong>of</strong> whom specialise in themanagement <strong>of</strong> HIV/AIDS, <strong>with</strong> either dedicated orshared junior staff.Outpatient workMost work in the specialty is outpatient based.STI clinics. In a 4-hour session, consultants shouldallow 3.5 hours for their own <strong>patients</strong> and 0.5 hour forconsultation, teaching and training. Clinical teachingforms a major part <strong>of</strong> the workload in teaching andnon-teaching hospitals. Fewer <strong>patients</strong> will be seenwhile teaching but numbers vary according to casemixand supporting staff. Adequate time must be allowed toC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 115


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>practise to a satisfactory standard, especially forconsultants <strong>working</strong> single-handedly.HIV clinics. Where dedicated HIV clinics are held,other healthcare pr<strong>of</strong>essionals should be availableincluding pharmacists, dietitians and clinicalpsychologists. Education on therapy and adherenceare essential elements <strong>of</strong> specialised support for <strong>patients</strong>.Other specialist clinics. <strong>Consultant</strong>s may undertakeother clinics depending on casemix and localrequirements. Many <strong>of</strong>fer consultant specialist clinics,eg for psychosexual problems and erectile dysfunction,and clinical problem clinics, eg for pelvic pain. Theserequire nursing support. Some services providemultidisciplinary clinics such as those for genital, skinor vulval disorders. These clinics provide opportunitiesfor teaching and training.Therapeutic procedure clinicsGenital warts are common and persistent and may betreated in dedicated sessions. Nurses <strong>working</strong> to patientgroup directives may provide treatment. Intravenousinfusions and inhalation therapy are provided asrequired.Specialist advice on callAccess to GUM/HIVopinion out <strong>of</strong> hours should be available. Coverarrangements should be appropriate to local need, maybe provided on a network basis and should be explicit.This includes advice on HIV post-exposure prophylaxis,support for A&E departments, in<strong>patients</strong> andsometimes problems in the community. Many servicesprovide a consultant on call. With the aid <strong>of</strong> junior staff,some emergencies may be managed over the telephone.Other specialist activity including activitiesbeyond the local servicesMany services have set up outreach clinics including inprimary healthcare settings and prisons.Clinically related administrationCorrespondence <strong>with</strong> primary care and other medicalcolleagues is routine. Writing reports for social services,asylum seekers and medicolegal reports is a significantworkload.7 Opportunities for integrated careThe reorganisation <strong>of</strong> commissioning provides anopportunity for integration <strong>of</strong> sexual health serviceswhich could lead to significant cost savings through:streamlining management structures; facilitating theprovision <strong>of</strong> community-based clinics, providing up tolevel 2 STI and contraception care; strengthening thechlamydia screening programme through coordinatedcontact tracing and a seamless pathway into specialistservices; and giving assurance that care is beingprovided to a consistently high standard, irrespective<strong>of</strong> point <strong>of</strong> access.8 Workforce requirements forthe specialtyWorkloadThe number <strong>of</strong> sexual health screens (SHS) conductedin GUM have approximately doubled in the last 8 yearsfrom 633,289 in 2003 to 1,258,952 in 2011. There hasbeen a 1.5-fold increase in the number <strong>of</strong> HIV testsconducted in GUM during the same period from400,166 in 2003 to 1,007,847 in 2011. Among HIVcases, 73,400 are now under care and these increaseannually. Service provision is changing <strong>with</strong> consultantsrequired to supervise staff – both nursing and specialtydoctors managing less complex cases – while seeingmore complex <strong>patients</strong> themselves.Current workforce numbersThere is a headcount <strong>of</strong> 396 (approximately345 whole-time equivalent (WTE)) consultants in theUK <strong>of</strong> whom 54% are male, from the RCP 2011 censusdata 6 (England, 364; Wales, 12; Northern Ireland, 5;and Scotland, 15). Of those consultants under 40 and 35years <strong>of</strong> age, 80% and 90% respectively are female. Fromavailable data, 51% <strong>of</strong> female consultants work less than10 programmed activities (PAs) compared <strong>with</strong> 7.3% <strong>of</strong>men. This is an important consideration for workforceplanning where many consultants are likely to want topractise part time at least for a proportion <strong>of</strong> their career.The rate <strong>of</strong> expansion has decreased to 1% in 2011and this contraction is likely to continue in the presentfinancial climate despite an increasing workload. Thereis likely to be a future reduction in numbers <strong>of</strong> highertrainees as part <strong>of</strong> cost savings irrespective <strong>of</strong> workforceplanning. Ninety (24%) consultants are over 55 years <strong>of</strong>age <strong>with</strong> a further 84 (22.6%) aged between 50 and 54.Number <strong>of</strong> consultant programmed activitiesrequired to provide a specialist service to apopulation <strong>of</strong> 250,000The figures below assume 40% <strong>of</strong> consultations will beundertaken by consultants. Patients will also be seen byother staff, including doctors in training, specialty116 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Genitourinary medicineTable 1 Specimen job plan for a consultant in genitourinary medicineActivity Workload Programmed activities (PAs)Direct clinical careOutpatient clinics/clinical supervision 10–12 <strong>patients</strong> per session 4–6Ward work including day care 0.5–2On call 0.5Patient-related administration 1.0Total number <strong>of</strong> direct clinical care PAs7.5 on averageSupporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong>healthcareOther NHS responsibilitiesExternal dutiesEducation and training, appraisal,departmental management and servicedevelopment, audit and clinical governance,CPD and revalidation, researcheg medical director/clinical director/leadconsultant in specialty/clinical tutoreg work for deaneries/royal colleges/specialistsocieties/Department <strong>of</strong> Health or othergovernment bodies, etc2.5 on averageLocal agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trustdoctors and nurse practitioners, but require consultantsupervision: 15,000 new and follow-up consultations per 250,000population per year 42 consultant weeks per year (8 weeks annualleave/bank holidays, 2 weeks study leave) 7.5 PAs for direct clinical care 4–6 clinics 20 minutes per appointment for routine GUM(more time for HIV <strong>patients</strong>). 10–12 <strong>patients</strong> seen per clinic 2,500–3,000 consultations per year per consultant.National consultant workforce requirementsWith modernistation <strong>of</strong> service delivery and the needto contain costs, robust arguments willbe needed for expansion. Increased consultant numbersare needed where there is insufficient service provision,eg in rural areas where providing prompt access isnot possible. Ideally, consultants should not be <strong>working</strong>single-handedly and they should work <strong>with</strong>in definednetworks. Trusts may resist replacing retiring consultantslike for like. However, particularly <strong>with</strong> GUMand HIV services, there are additional factors that mustbe considered where greater consultant numbers maybe required: demographic mix, numerical population,HIV cohort, deprived areas, risk groups such asasylum seekers, ethnic minority groups, young people,towns and cities <strong>with</strong> a university or other trainingestablishments. The role <strong>of</strong> consultants encompassesthe provision <strong>of</strong> supervision <strong>of</strong> other healthcarepr<strong>of</strong>essionals, providing the clinical governanceframework and providing medical leadership acrossa locality that may involve primary and secondarycare, and private providers. These needs, along <strong>with</strong>the additional expectations <strong>of</strong> revalidation, teaching andtraining, will require maintaining consultant numbersdespite the specialty being commited to modernisation<strong>of</strong> practice and other ways <strong>of</strong> delivering the service.With present uncertainties, a reduction in proposednumber <strong>of</strong> consultants from the previous 1 WTE per84,000 to 2 WTE per 250,000 is suggested. In the UK(61 million population), this would equate to 480 WTE.The Centre for Workforce Intelligence 7 predicts that, by2018, 439 WTE will be reached. It suggests noadjustment to the number <strong>of</strong> training posts, taking intoaccount population growth, demographics andhistorical supply. The rate <strong>of</strong> retirement will have asignificant influence on potential vacancies.Additonally, a proportion <strong>of</strong> trainees enrolled in higherspecialist training is training part time and thereforetaking longer to reach CCT.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 117


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>9 <strong>Consultant</strong> work programme/specimenjob planDirect clinical careDepending on the pr<strong>of</strong>ile <strong>of</strong> their workload andspecialist interests, consultants will undertake 7.5 directpatient care PAs divided between outpatient andinpatient work (see Table 1). Many consultants haveoutpatient clinics on more than one site.10 Key points for commissioners1 Sexual health services should be open access,confidential and free to users irrespective <strong>of</strong> theirplace <strong>of</strong> residence.2 Services should be commissioned <strong>with</strong>in aframework <strong>of</strong> local clinical networks supported byconsultant-led specialist services to ensuremaintenance <strong>of</strong> high standards, consistency <strong>of</strong> careand clinical governance.3 Commissioners should require all providers toproduce evidence <strong>of</strong> participation in national audit.4 Commissioners should require all providers toensure that staff delivering services have beenappropriately trained and are competent to carryout their roles. Providers should be required todemonstrate the use <strong>of</strong> validated competencyassessment for all clinical staff.5 BASHH standards for the management <strong>of</strong> STI andkey performance indicators listed in this documentshould be incorporated into the localcommissioning process for all levels <strong>of</strong> service toensure consistency <strong>of</strong> care and to enable meaningfulperformance management <strong>of</strong> services.References1 Department <strong>of</strong> Health. National strategy for sexual healthand HIV. London: DH, 2001.2 British HIV Association. Standards for HIV clinical care2013. www.bhiva.org/documents/Standards-<strong>of</strong>-care/BHIVAStandardsA4.pdf3 British Association for Sexual Health and HIV. Standardsfor the management <strong>of</strong> sexually transmitted infections(STIs). London: BASHH, January 2010. www.bashh.org/documents/25134 Department <strong>of</strong> Health. Health Services Building Note(HBN) 12, supplement 1 – sexual health clinics.London:DH, 2005.5 British Association for Sexual Health and HIV. BASHHClinical effectiveness group guidelines. www.bashh.org/guidelines6 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> theUnited Kingdom. Census <strong>of</strong> consultant <strong>physicians</strong> andmedical registrars in the UK, 2011 data and commentary.London: RCP, 2013.7 Centre for Workforce Intelligence. Recommendation forgenitorinary medicine training 2011. www.cfwi.org.uk/intelligence/cfwi-medical-summary-sheets/recommendation-for-genitourinary-medicinetraining-2011118 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Geriatric medicineGeriatric medicineDr Zoe Wyrko MBChB MMedSci MRCP(London) <strong>Consultant</strong> geriatrician1 Description <strong>of</strong> the specialtyGeriatric medicine is the branch <strong>of</strong> general medicineconcerned <strong>with</strong> all aspects <strong>of</strong> health and illness in olderadults. Geriatricians possess the specialist skills neededto diagnose, manage and treat conditions occurring in aphysically and mentally frail section <strong>of</strong> the population.Additional challenges are provided by the fact that olderpeople have different patterns <strong>of</strong> disease presentationwhen compared to younger adults, they respond totreatments and therapies in different ways, and theyfrequently have complex social needs that are related totheir chronic medical conditions.The <strong>patients</strong> are traditionally adults aged over 65 years,but younger people <strong>with</strong> complex needs can also benefitfrom input by a geriatrician. Those who gain the mostbenefit from specialist geriatrician input are the frailelderly. Frailty <strong>of</strong>ten presents as non-specific ill health(the ‘geriatric giants’ <strong>of</strong> falls, confusion, incontinenceand immobility) but leads to prolonged hospital staysand poorer outcomes. 1,22 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralTo provide integrated holistic care for older people,geriatric medical services should cross the boundarybetween primary and secondary care. Care pathwaysshould consider the physical and psychologicalneeds <strong>of</strong> normal ageing, together <strong>with</strong> the crisesand potential deterioration associated <strong>with</strong> acuteillness.An acutely ill older person should be assessed as soonas possible using appropriate diagnostic and imagingfacilities, usually in an acute district general hospital(DGH) or teaching hospital. It is vital that older peoplearenotdeniedaccesstothebest<strong>of</strong>diagnosticserviceson the basis <strong>of</strong> their age and the organisation <strong>of</strong>community and hospital services should be gearedtowards this aim.No clear evidence exists that any one pattern <strong>of</strong> elderlyadmission system is superior (age-related, needs-relatedor integrated <strong>with</strong> general medicine), so the formatchosen needs to be appropriate to the facilities andsystems already available. There is increasing interest ininvolving geriatricians in the accident and emergency(A&E) department and medical admissions units t<strong>of</strong>acilitate the early comprehensive assessment, andappropriate subsequent treatment environment, <strong>of</strong> frailolder people. Patients admitted urgently to geriatricmedical services might be referred directly by their GP,attend the A&E department and be referred onwards foradmission, or be transferred from other acute areas suchas surgical or psychiatric facilities.The increasing importance <strong>of</strong> involvement <strong>of</strong>geriatricians <strong>with</strong> the care <strong>of</strong> older people in specialtiesother than medicine is becoming apparent, <strong>with</strong> earlygeriatric assessment routinely taking place in those underthe care <strong>of</strong> orthopaedic surgeons for fragility fractures.Referrals for rehabilitation are taken from almost allspecialties at a later stage in a patient’s hospital stay.Rehabilitation aims to optimise or maintain physicalfunction and, following <strong>patients</strong>’ admission to hospital,should start as soon as they are physically able.Geriatrics is the parent specialty for stroke medicine,and both the acute stroke and stroke rehabilitationservices are <strong>of</strong>ten led by geriatricians.Community models <strong>of</strong> careCommunity geriatrics is a growing subspecialty, <strong>with</strong>some consultants <strong>working</strong> exclusively in thecommunity, although the majority have sessionalcommitments to both community work and acutehospitals. A job plan may include time spent incommunity hospitals, as well as supportingintermediate care services, community matrons andcare homes. A wide variety <strong>of</strong> work patterns arepossible, but it is vital that integrated pathwaysinvolving community services are developed locally,<strong>with</strong> community geriatricians <strong>working</strong> closely <strong>with</strong> GPs,district and specialist nurses, and allied pr<strong>of</strong>essionals.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 119


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>The consultants will <strong>of</strong>ten lead clinical governanceprocesses and teaching for community services. Theyare specifically required to supervise clinically and tosupport any GPs <strong>with</strong> a special interest (GPwSIs) inelderly care.Relationship <strong>with</strong> other services and agenciesMultidisciplinary <strong>working</strong> necessitates close liaison <strong>with</strong>many complementary services (see Table 1), as well asthe mainstream specialties in a DGH.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong>Involving <strong>patients</strong> in decisions about theirtreatmentGeriatricians are committed to rooting out ageism inthe delivery <strong>of</strong> medical care and recognise thatcompetent informed adults have an established right torefuse medical procedures – sometimes in advance.Respect for patient autonomy is at the centre <strong>of</strong>practice, particularly when dealing <strong>with</strong> advancedirectives and issues relating to nutrition in <strong>patients</strong> <strong>of</strong>advanced old age. Medico-legal topics such as power <strong>of</strong>attorney, Court <strong>of</strong> Protection and the Mental CapacityAct 2005 are important parts <strong>of</strong> everyday geriatricmedical practice. Geriatricians regularly seek <strong>patients</strong>’and carers’ views on end-<strong>of</strong>-life care, cardiopulmonaryresuscitation, assisted ventilation, artificial feeding andother ethical issues.Patients <strong>with</strong> chronic conditions and the role<strong>of</strong> the carerGeriatricians recognise the importance <strong>of</strong> involvinginformal carers in decisions about complex treatmentin old age and consider a patient’s quality <strong>of</strong> lifeand a disability-free life expectancy as important goals<strong>of</strong> treatment rather than absolute longevity. Patient andcarer support groups may have a role in the management<strong>of</strong> <strong>patients</strong> <strong>with</strong> chronic conditions in older life,particularly those <strong>with</strong> conditions such as stroke,Parkinson’s disease and dementia. In addition, <strong>patients</strong>’and carers’ views form an important part <strong>of</strong> the clinicalgovernance process in geriatric medical departments inhospitals – either individually or as part <strong>of</strong> focus groupsthat look at complaints and the patient experience.Older people should be treated as individuals at all times,be <strong>of</strong>fered a choice <strong>of</strong> treatment and be involved in thediscussions planning their future care. Services need to beTable 1 Medical and paramedical services supportingthe assessment and rehabilitation <strong>of</strong> older peopleDomainActivities <strong>of</strong> dailylivingCare managementCommunicationEliminationPalliative careMental stateNutritionMobilitySpecialist nursesServicesOccupational therapySocial work servicesSpeech and language therapyAudiologyHearing therapyOphthalmologyOptician servicesDental servicesContinence adviserStoma therapistUrological or gynaecological servicesUrodynamic assessmentPersonal laundry servicesSpecialist pain reliefHospice supportPsychiatry <strong>of</strong> old ageClinical psychologyDietetic adviceEnteral and parenteral feeding servicesincluding percutaneous endoscopicgastrostomy (PEG)Dental servicesVide<strong>of</strong>luoroscopyPhysiotherapyWheelchair and aid suppliesOrthoticsPodiatryOrthopaedic servicesChiropodyChronic obstructive pulmonary diseaseHeart failureParkinson’s diseaseDiabetesTissue viabilityDementiaFracture or orthogeriatricmade easily accessible, regardless <strong>of</strong> provider, by involvingolder people and their carers in service planning.There are a number <strong>of</strong> areas for which all specialistelderly care units should have policies. These include:maintenance <strong>of</strong> dignity, privacy and humanity in care;end-<strong>of</strong>-life care/advanced care planning and ‘do notresuscitate’ orders; and provision <strong>of</strong> written informationfor <strong>patients</strong> about life in hospital, the choices to bemade, discharge plans and the timescales involved.120 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Geriatric medicinePromoting health and self careSpecialist elderly services should develop a culture <strong>of</strong>health promotion alongside disease management andrehabilitation. Geriatricians should discuss healthpromotion and preventative healthcare programmes,which should be regarded as a legitimate subspecialty,<strong>with</strong> commissioning boards. Health promotion postersand literature specifically directed at this age groupshould be readily available in patient-contact areas.4 Interspecialty and interdisciplinary liaison<strong>Consultant</strong>s in geriatric medicine pioneered the concept<strong>of</strong> interdisciplinary teams, <strong>working</strong> to ensure thatmedical illness and functional capacity in older peopleare assessed and treated. It is the essence <strong>of</strong> goodpractice in acute assessment and rehabilitation settingsfor the consultant to lead at least one interdisciplinarycase conference per week. Such team<strong>working</strong> <strong>with</strong> alliedhealth pr<strong>of</strong>essionals, social workers and communitystaff, based on multiple individual assessments that leadto comprehensive geriatric assessment (CGA), is thehallmark <strong>of</strong> a high-quality service. Case conferencesmaybelessfrequentinlong-termcare.5 Delivering a high-quality serviceA high-quality service is defined as early access to anMDT, led by a geriatrician specialising in thecomprehensive assessment <strong>of</strong> older people. This can bein an acute hospital, day hospital or outpatient setting,<strong>with</strong> subsequent access to further specialist input whenindicated. Community rehabilitation and crisisintervention teams should be based on aninterdisciplinary model <strong>with</strong> specialist medicalinvolvement.Quality tools and frameworksRelevant quality standards should be adhered to, such asthe National Institute for Health and Care Excellence(NICE) quality standards in England, and relevantoutcomes measures achieved. Particular attentionshould be paid to stroke, 3,4 dementia and falls;pathways should be in place to assess and addresscontinence and poor nutrition. 5 In addition to nationalpolicies, the British Geriatrics Society (BGS) hasguidelines, policy statements and statements <strong>of</strong> goodpractice for many aspects <strong>of</strong> the care <strong>of</strong> older people. 6Education, training and support programmes fornon-specialist wards and clinicians not specialising inthe care <strong>of</strong> older people should be available, andorganisations should have a system <strong>of</strong> quality assuranceto facilitate clinical governance and ensure maintenance<strong>of</strong> the highest possible standards.6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialtyGeriatricians work in a broad range <strong>of</strong> settings, <strong>with</strong>duties differing widely in content and load across theUK, reflecting variations in local supporting services,specialist activity, geographical sites covered andinvolvement in the acute emergency take. No job islikely to be identical to another.In many areas, consultant geriatricians participate in theacute unselected take for adults <strong>of</strong> all ages. In a growingnumber <strong>of</strong> hospitals where the main medical take isdelivered by acute <strong>physicians</strong>, geriatricians are delivering7-day input to provide a rapid, targeted, comprehensivegeriatric assessment to case-find frail people at the frontdoor and prevent unneeded hospital admissions. Suchmodels <strong>of</strong> care are frequently known as Geriatrician <strong>of</strong>the Day, OPAL teams or Interface Geriatrics. Otherswork alongside specialty-based <strong>physicians</strong> so they canpreferentially care for older people on an age- orneeds-related basis. In all situations, geriatricians mustensure an appropriate balance between their emergencyrole and other duties, particularly supervision <strong>of</strong>rehabilitation and delivery <strong>of</strong> subspecialty services, suchas falls management, stroke care or orthogeriatrics.Most consultants in geriatric medicine maintain specificsessional commitment to the inpatient core areas <strong>of</strong>acute assessment and rehabilitation. In addition, theywill have some community responsibilities throughoutpatient, day hospital and outreach facilities. Thedevelopment <strong>of</strong> intermediate or post-acute care outsidethe hospital will necessitate increasing cooperation <strong>with</strong>primary care.Acute inpatient careModels <strong>of</strong> care delivery will vary depending on casemix,bed numbers and support staff. Regular consultantward rounds should take place at least twice per week,and be combined <strong>with</strong> frequent multidisciplinary‘board rounds’. A ward round <strong>of</strong> 25 (+/−5) <strong>patients</strong>should take a programmed activity (PA); therefore thiswork would be equivalent to 2–3 PAs per week.Involvement <strong>of</strong> relatives is vital in the ongoing care andrecovery <strong>of</strong> this complex group <strong>of</strong> <strong>patients</strong>, and aC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 121


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>further 3–4 hours per week (1 PA) should be consideredto allow for meeting <strong>with</strong> next <strong>of</strong> kin.Within a department there should be sufficient capacityfor consultants to provide prospective leave cover forcolleagues, including being able to do a ward round <strong>of</strong>their <strong>patients</strong>.RehabilitationNumbers <strong>of</strong> rehabilitation <strong>patients</strong> looked after by aconsultant geriatrician, <strong>with</strong> supporting medical staff,will vary depending on where the rehabilitation istaking place. In a traditional hospital setting <strong>with</strong> directsupervision (either acute or community), this could beexpected to be an average ward ie 24–30 <strong>patients</strong>. In a‘virtual ward’ or intermediate-care setting, this numberwould vary depending on the expertise <strong>of</strong> the leadstaff, and complexity <strong>of</strong> the <strong>patients</strong>. A consultantnormally would be expected to complete at least onerehabilitation ward round per 20 <strong>patients</strong> eachweek, and this would include a meeting <strong>of</strong> themultidisciplinary team (MDT).In addition, the consultant is likely to require onefurther PA for meeting relatives, reviewing unstable<strong>patients</strong>, special case conferences and troubleshooting.Community workDepartments <strong>of</strong> geriatric medicine should expect to playa significant role in the community, including <strong>working</strong>in teams to deliver intermediate care; reviewing <strong>patients</strong>in care homes (NHS and private sector) – <strong>of</strong>ten inconjunction <strong>with</strong> community matrons or other expertallied health pr<strong>of</strong>essional colleagues; assessing <strong>patients</strong>who require long-term care; and providing homeassessments at the request <strong>of</strong> colleagues in primary care.These duties <strong>of</strong> community geriatricians may beundertaken in partnership <strong>with</strong> social services, byGPwSIs in older people and perhaps by nurse ortherapist consultants.Continuing careWhen continuing care work is undertaken, a consultantgeriatrician would be expected to have directresponsibility for around 30 continuing care beds andwould normally be expected to review the needs <strong>of</strong> the<strong>patients</strong> at least once every two weeks.Referral work including interspecialty andinterdisciplinary liaisonA consultant would expect to deal <strong>with</strong> around five to10 referrals per week. Absolute numbers will depend onconsultant numbers and local provision <strong>of</strong> specialistliaison services <strong>with</strong>in an acute hospital.Outpatient workTable 2 considers the requirements <strong>of</strong> outpatient clinicsfor general geriatric medicine and general internalmedicine (GIM).Table 2 Requirements <strong>of</strong> outpatient clinics for general geriatric medicine and GIM <strong>with</strong> indicative timings forconsultationsTime (minutes)Type <strong>of</strong> patientNewconsultation ∗Follow-upconsultationAdministration †(per patient)Training andpatient discussion(per patient)<strong>Consultant</strong> and ST4–7Complex elderly care patient ‡ 45–60 20 10 10General medical patient (young or old) § 15–25 10 5 10ST1–3Complex elderly care patient ‡ 60 30 10 10General medical patient (young or old) § 45 15 5 10ST = specialty trainee.∗ A new consultation would cover patient history, an examination, discussion <strong>of</strong> findings, reviewing or ordering investigations and a management plan.† Administration may be during clinic or at another time and includes dictation, reviewing results, phone calls, electronic correspondence, etc.‡ Complex conditions such as multiple problems, memory loss, Parkinson’s disease, falls and incontinence.§ General conditions such as transient ischaemic attacks, weight loss, anaemia, gastrointestinal problems and ischaemic heart disease.122 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Geriatric medicineDay hospitalsA high-turnover day hospital might expect to see 600new <strong>patients</strong> a year in a 30-place unit. Each consultantshould expect to have responsibility for around 12–15<strong>patients</strong> at any one time. The consultant should holdinterdisciplinary case conferences every one to twoweeks.Services beyond the base hospitalThese may include clinics at other hospitals, outreachclinics, domiciliary work and hospice work.Work to maintain and improve the quality <strong>of</strong> careThis work encompasses duties in clinical governance,pr<strong>of</strong>essional self-regulation, continuing pr<strong>of</strong>essionaldevelopment (CPD) and education, and the training <strong>of</strong>others. For many consultants at various times in theircareers, it may include an educational role, research,clinical management and provision <strong>of</strong> specialist adviceat local, regional and national levels.The BGS has produced detailed guidance on clinicalgovernance and the amount <strong>of</strong> time that is required t<strong>of</strong>ulfil these requirements. Generally, a lead clinician inclinical governance needs one session <strong>of</strong> PA, whileparticipation in clinical governance would needabout 0.25 PA. This does not include any timerequired for revalidation, CPD or participation inappraisal, which are mandatory activities for allconsultants.Leadership roles and development <strong>of</strong> the serviceDepartments <strong>of</strong> geriatric medicine are expected to takean active role in the development <strong>of</strong> services for olderpeople in primary and secondary care. Such work fordesignated individuals should be recognised in thejob-planning process, alongside other managementduties such as running the department and takingresponsibility for the delivery <strong>of</strong> teaching, clinicalgovernance and the research agenda for a group <strong>of</strong>geriatricians.Academic geriatric medicineAcademic geriatricians usually make a significantcontribution to the NHS service for older people buthave fewer clinical PAs to allow for universitycommitments, which include teaching and research.Their job plans should reflect this mix <strong>of</strong> university andNHS work. <strong>Consultant</strong> geriatricians teach not onlyundergraduate medical students but also otherdisciplines. Many NHS geriatricians teach andundertake research when there is no academicdepartment. All academic and NHS geriatricians have aresponsibility for the postgraduate training <strong>of</strong> higherspecialist trainees in geriatric medicine, whichculminates in the award <strong>of</strong> a Certificate <strong>of</strong> Completion<strong>of</strong> Training (CCT).7 Opportunities for integrated careThere is a growing awareness <strong>of</strong> the scope for geriatricmedicine to integrate throughout healthcare services.As referred to in other sections, the importance <strong>of</strong>geriatrician involvement in other areas <strong>of</strong> communitycare, such as care homes rather than just the traditionalcommunity hospitals, is becoming apparent. The newterm ‘interface geriatrics’ describes the ability toperform a comprehensive geriatric assessment at thefront door <strong>of</strong> the general hospital to ensure that an olderperson is placed appropriately in order to receive thecare they need. This might be in an acute medical bed,accommodation <strong>with</strong>in a community facility, or care athome <strong>with</strong> either domiciliary or early outpatient careand therapy.Geriatrician involvement <strong>with</strong> older orthopaedic<strong>patients</strong> has been shown to improve both mortality andmorbidity, and there is clear scope for similarinvolvement to be extended throughout any surgeryfor older people, whether elective or emergencyprocedures.8 Workforce requirements for the specialtyIn 2009, there were 1,205 consultant geriatricians; anincrease <strong>of</strong> 8.5% on 2008. Half <strong>of</strong> the workforce aged50 years and under was female compared to 20% forconsultants aged 55 years and over. In the next fiveyears, it is expected that 12.4% <strong>of</strong> all consultants willreach 65 years and are likely to retire. The majority <strong>of</strong>consultants (86.2%) work full time. The averagenumber <strong>of</strong> PAs per week was 11.5, <strong>with</strong> the actualnumber <strong>of</strong> PAs worked being 12.4.The number <strong>of</strong> trainee posts stood at 508 in 2009,a drop <strong>of</strong> 15 from 2008. Just under half (49.6%) <strong>of</strong>trainees were women and 34% <strong>of</strong> all trainees hadchildren. The impact <strong>of</strong> the European Working TimeDirective has been mixed, <strong>with</strong> 63.7% <strong>of</strong> traineesreporting a reduction in the quality <strong>of</strong> training but37.4% saying it has improved their work balance. Theaverage frequency <strong>of</strong> on-call work was one in 10 forweekdays and one in 11 on weekends.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 123


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>The ratio by which the population is served by awhole-time equivalent (WTE) consultant geriatricianvaries considerably across the country – from the lowestratio in Wales, Yorkshire and Humber, and Scotland,<strong>with</strong> one geriatrician per 46,000 <strong>of</strong> the population,compared to the highest ratio <strong>of</strong> 76,000 to 86,000 in theEast and West Midlands. 7To care for the population older than 75 years, the BGShas recommended that there should be a minimum <strong>of</strong>one WTE geriatrician per 50,000 population (one WTEfor 4,000 people older than 75 years), although thenumbers needed are likely to increase further <strong>with</strong> theincreasing age and frailty <strong>of</strong> the population.9 <strong>Consultant</strong> work programme/specimenjob planTable 3 provides an example <strong>of</strong> a consultant job plan.10 Key points for commissioners1 Providing excellent care for older people results inexcellent care for younger <strong>patients</strong>; the converse israrely true.2 Geriatrician input early in a patient’s hospitalstay (in the A&E department or clinical decisionunit) leads to better care in the best environmentfor that person. This could be at home <strong>with</strong>support, in a community setting, or in the acutefacility.3 Geriatric medicine is the parent specialty forstroke, and the vast majority <strong>of</strong> post-strokerehabilitation is undertaken by geriatricians <strong>with</strong>an interest in the condition.4 Improved and increased levels <strong>of</strong> care taking placein the community cannot be achieved <strong>with</strong>outteams led by geriatricians <strong>working</strong> closely <strong>with</strong>primary care and other providers.Table 3 Example <strong>of</strong> a job planActivity Workload Programmed activities (PAs)Direct clinical careAcute ward rounds (including interdisciplinarymeetings and interviewing relatives)Rehabilitation ward rounds (includinginterdisciplinary meetings and interviewing relatives)20–25 <strong>patients</strong> 2–320 <strong>patients</strong> 1–2Intrahospital liaison or domiciliary visits 0.5General or geriatric medicine clinicNumbers will depend on casemix and theavailability <strong>of</strong> specialty trainees1.0Specialist clinic, day hospital, other subspecialty work 1.0Post-take ward round or on-call work 1.0Patient-related administration 1.0Total number <strong>of</strong> direct clinical care PAs7.5–9.5 on averageSupporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong>healthcareOther NHS responsibilitiesExternal dutiesEducation and training, appraisal,departmental management and servicedevelopment, audit and clinicalgovernance, CPD and revalidation,researcheg medical director, clinical director, leadconsultant in specialty, clinical tutorwork for deaneries, royal colleges,specialist societies, Department <strong>of</strong> Healthor other government bodies, etc2.5 on averageLocal agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trust124 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Geriatric medicine5 The specialist discharge planning skills andknowledge held by geriatricians can lead to shorterlengths <strong>of</strong> hospital stay, <strong>with</strong>out subsequent earlyreadmission.6 Geriatricians are essential in the care <strong>of</strong> olderpeople <strong>with</strong> fragility fractures and have a role toplay both preoperatively and in the rehabilitationphase.7 Following the 2010 National Confidential Enquiryinto Patient Outcome and Death (NCEPOD)report Elective and emergency surgery in theelderly, 8 there is a growing role for geriatriciansto be involved in all surgical admissions in olderpeople.References1 Lally F, Crome P. Understanding frailty. Postgrad Med J2007;83:16–20.2 Young J, Robinson M, Chell S et al. Aprospectivebaseline study <strong>of</strong> frail older people before theintroduction <strong>of</strong> an intermediate care service. Health SocCare Community 2005;13:307–12.3 National Institute for Health and Care Excellence.Diagnosis and initial management <strong>of</strong> acute stroke andtransient ischaemic attack (TIA). London: NICE, 2008.http://guidance.nice.org.uk/CG684 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. National clinical guidelinesfor stroke, 3rd edn. London: RCP, 2008.5 Age UK. Don’t go hungry in hospital leaflet. www.ageuk.org.uk/documents/en-gb/dont%20go%20hungry%20in%20hospital%20leaflet.pdf?dtrk=true6 British Geriatrics Society. Morris J, Beaumont D.Standards <strong>of</strong> medical care for older people: expectations andrecommendations. Compendium document 1.3 (1997,revised 2003 and 2007). London: BGS, 2007.7 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK.Census <strong>of</strong> consultant <strong>physicians</strong> and medical registrars inthe UK 2009: data and commentary. London: RCP, 2010.8 National Confidential Enquiry into Patient Outcome andDeath (NCEPOD). Elective and emergency surgery in theelderly: an age old problem. London: NCEPOD, 2010.www.ncepod.org.uk/2010eese.htmC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 125


2 Specialties HaematologyHaematologyDr Mike Galloway <strong>Consultant</strong> haematologist1 Description <strong>of</strong> the specialty Haematologists provide an interpretative andadvisory service based on laboratory results andHaematologists are both clinicians and laboratorydirect the appropriate referral <strong>of</strong> <strong>patients</strong> <strong>with</strong>specialists who engage in the following activities:abnormal laboratory results <strong>with</strong>in an acceptabletimeframe. This may involve providing support and <strong>working</strong> <strong>with</strong>in a specialty clinical team, taking full written advice to the GP to allow care to be managedclinical responsibility for <strong>patients</strong> <strong>with</strong> a wide range in the primary-care setting.<strong>of</strong> haematological disorders (see Table 1) providing interpretation <strong>of</strong> laboratory results and Clinical serviceadvising other hospital clinicians and GPs on Clinical referrals come from primary, secondary orappropriate clinical managementtertiary care. The level <strong>of</strong> subspecialisation varies, and providing pr<strong>of</strong>essional direction and having clinical many haematologists have a subspecialty interest inresponsibility for the haematology and transfusion addition to their commitment to laboratory and generallaboratoryhaematology. providing a laboratory, clinical and consultativeservice 24 hours a day.Haematological malignancyThe British Committee for Standards in HaematologyHaematologists undergo general pr<strong>of</strong>essional training (BCSH) has defined three major levels <strong>of</strong> care for <strong>patients</strong>in medicine followed by specialist training in all aspects <strong>with</strong> haematological malignancies (see Table 2). 2<strong>of</strong> clinical and laboratory haematology. Many undertake The National Institute for Health and Care Excellencea period in research. Most develop further expertise in (NICE) Guidance on cancer services recommendsone or more subspecialties.that <strong>patients</strong> <strong>with</strong> haematological cancers are managedby multidisciplinary haemato-oncology teams servingMain disease patternsa population <strong>of</strong> more than 500,000, <strong>with</strong> link networksTable 1 summarises main haematological disease between hospitals and that the treatment <strong>of</strong> acutepatterns and numbers <strong>of</strong> <strong>patients</strong> seen annually. leukaemia be limited to hospitals that treat at least five<strong>patients</strong> annually. 3 As a result, the number <strong>of</strong> units thatcan deliver the level 2b chemotherapy that is required for2 Organisation <strong>of</strong> the service and patterns <strong>patients</strong> <strong>with</strong> acute leukaemia has been reduced.<strong>of</strong> referralAll units that undertake stem cell transplantationA typical service(SCT), both autologous and allogeneic, are accreditedby JACIE, which is the Joint Accreditation Committee <strong>of</strong>Laboratory service the International Society for Cellular Therapy (ISCT)The haematology laboratory provides a diagnosticand the European Group for Blood and Marrowand blood bank service to its host institution, whichTransplantation (EBMT).may include highly specialised investigations tosupport specialist clinical services. It also provides aHaemoglobinopathiesrange <strong>of</strong> tests for primary care, which may allowSickle cell disease and thalassaemia represent adiagnosis <strong>of</strong> a spectrum <strong>of</strong> haematological disease insignificant part <strong>of</strong> the haematologist’s workload in areasthe community. The source <strong>of</strong> specimen referral<strong>of</strong> the UK where the prevalence is high. In London,varies across hospitals, <strong>with</strong> the proportion <strong>of</strong>sickle cell disease is now one <strong>of</strong> the most commonrequests from primary care ranging from 30% toreasons for admission to hospital and has the highest50%. 1 rate <strong>of</strong> multiple admissions for individual <strong>patients</strong>. 4,5C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 127


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Incidence <strong>of</strong> haematological disease and numbers <strong>of</strong> <strong>patients</strong> seen annuallyPopulationDisease or treatment England and Wales Per 1,000,000 Per 500,000 Per 250,000Acute leukaemia 2,400 48 24 12CML 500 10 5 2–3CLL 4,000 80 40 20NHL – high grade 2,000 40 20 10NHL – low grade 5,000 100 50 25Hodgkin’s lymphoma 1,200 24 12 6Myeloma 3,000 60 30 15MDS, MPD and other 2,000 40 20 10Oral anticoagulant treatment 520,000 10,000 5,000 2,500Venous thrombosis 78,000 1,500 750 375Thrombophilia 2,600,000 50,000 25,000 12,500Symptomatic thrombophilia 30,000 600 300 150CLL = chronic lymphocytic leukaemia; CML = chronic myeloid leukaemia; MDS = myelodsyplastic syndrome;MPD = myeloproliferative disease; NHL = non-Hodgkin’s lymphoma.Patients require comprehensive care, which may includechronic transfusion programmes, iron chelation andfrequent hospital admissions for the treatment <strong>of</strong> sicklecrisis. National standards for the management <strong>of</strong><strong>patients</strong> <strong>with</strong> haemoglobinopathies direct serviceswhich are delivered in the secondary and tertiary caresettings and in the community. Linked newborn andantenatal screening for haemoglobinopathy is aDepartment <strong>of</strong> Health (DH) initiative that requires adesignated lead clinician and careful links <strong>with</strong> obstetricclinics.Thrombosis and haemostasisThe care <strong>of</strong> <strong>patients</strong> <strong>with</strong> haemophilia and otherinherited bleeding disorders is organised throughhaemophilia comprehensive care centres usingmanagement guidelines produced by the UKHaemophilia Centre Doctors’ Organisation(UKHCDO) and the National Service Specification forBleeding Disorders. Patients require lifelong care, <strong>with</strong>input from other disciplines including orthopaedics.A consultant haematologist in each hospital is <strong>of</strong>tenresponsible for supervising the control <strong>of</strong> oralanticoagulants (OACs). The consultant may also lead athrombosis service, directing a multidisciplinaryapproach to the management <strong>of</strong> the risk <strong>of</strong> thrombosisand the investigation and treatment <strong>of</strong> venousthromboembolism (VTE). This aspect <strong>of</strong> a consultanthaematologist’s work increased significantly during2010 following the development <strong>of</strong> national targets inEngland for VTE risk assessment that have been set inthe Commissioning for Quality and Innovation(CQUIN) payment framework and the publication <strong>of</strong>the NICE standards on the prevention <strong>of</strong> VTE.Transfusion medicineOne consultant haematologist is usually responsible forthe hospital blood bank and transfusion services. Theconsultant will be a member <strong>of</strong> the hospital transfusioncommittee, together <strong>with</strong> a specialist practitioner <strong>of</strong>transfusion (SPOT) and the senior biomedical scientist(BMS) <strong>of</strong> the hospital blood bank. This team isresponsible for ensuring that appropriate policies andguidelines are in place to guarantee the safety <strong>of</strong> bloodtransfusion and the best use <strong>of</strong> blood to meet therequirements <strong>of</strong> British and European legislation.Hospital blood banks must ensure that all bloodcomponents can be traced accurately from donor torecipient.128 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties HaematologyTable 2 A summary <strong>of</strong> the staffing requirements and facilities for different levels <strong>of</strong> care as outlined by theBritish Committee for Standards in Haematology (BCSH) 2Levels<strong>of</strong> careIntensity and complexity<strong>of</strong> treatment regimen Medical staffing Nurse staffing Facilities1 Usually outpatient based<strong>with</strong> regimens that areunlikely to result inbone-marrow suppression<strong>Consultant</strong>s not usuallybased on site but work aspart <strong>of</strong> a wider network andprovide sessional input;should be 24-hourtelephone access toconsultant adviceDedicated specialist nursesessions provision duringthe <strong>working</strong> week <strong>with</strong>pr<strong>of</strong>essional links to level 2or above centreAccess to day care facility;in<strong>patients</strong> should beadmitted as part <strong>of</strong> thegeneral medical admissionprocess2aOutpatient and day-casebased <strong>with</strong> regimens thatmay result in short,predictable periods <strong>of</strong>bone-marrow suppression<strong>Consultant</strong>s should providecover on a 24-hour/7days-a-week basis; this maybe provided by cross cover;junior medical staff shouldbe available to support carefor in<strong>patients</strong>Dedicated specialist nurseprovision during the<strong>working</strong> weekAccess to day-case facilitiesthat include facilities forintravenous infusions <strong>of</strong> along duration; inpatientbeds should be available onone ward designated forhaematology <strong>with</strong> accessto single rooms <strong>with</strong>en-suite facilities2bIncludes inpatientregimens that cause apredictable prolongedperiod <strong>of</strong> bone-marrowsuppression24-hour on-site consultantcover <strong>with</strong> designatedjunior trainee or non-careergrade staff provided duringthe <strong>working</strong> week24-hour cover byhaemato-oncology trainednurses <strong>with</strong> resources toachieve a nurse:patientratio <strong>of</strong> 1:2 for in<strong>patients</strong>requiring high dependencynursing, if required; thereshould be on-site dedicatednurse specialists during theweekAs for 2a <strong>with</strong> additionalprovision for direct accessto a dedicatedhaematology ward3 Includes inpatientregimens that are complexand have a high incidence<strong>of</strong> complications; includestreatment for rarehaematologicalmalignanciesAs for level 2b plus 24-hourspecialist middle-grademedical staff cover duringthe weekdays andweekendsAs for 2bAs for 2bPaediatric haematologyA small number <strong>of</strong> haematologists specialise in children<strong>with</strong> benign and malignant haematological disorders.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareInteraction <strong>with</strong> <strong>patients</strong>Patients <strong>with</strong> any haematological disorder receive adetailed explanation <strong>of</strong> their disorder (including easilyunderstood written information) and its treatment. Thisis usually provided in conjunction <strong>with</strong> a haematologyspecialist nurse, and adequate time is allowed for jointdecision making and discussion about the expectedbenefits and toxicities <strong>of</strong> treatment. Patients should be<strong>of</strong>fered treatment in a clinical trial when available, andwritten informed consent should be obtained.Involving <strong>patients</strong> in decisions about theirtreatmentPatient education plays a crucial role in the safemanagement <strong>of</strong> <strong>patients</strong> <strong>with</strong> haematological disordersby enabling <strong>patients</strong> to recognise symptoms that needurgent self-referral, such as fever and bleeding.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 129


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Many <strong>patients</strong> and their carers are taught to administerpart <strong>of</strong> their treatment at home, including coagulationfactors for inherited bleeding disorders, subcutaneousheparin, iron chelation and home chemotherapy.Patients on OACs may self-test at home, <strong>with</strong> dosingsupervised by a nurse specialist by telephone.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>Multidisciplinary team (MDT) meetings for <strong>patients</strong><strong>with</strong> haematological malignancies, severe bleedingdisorders, haemoglobinopathies andpregnancy-associated haematological problems areroutine in haematology practice. Laboratory-focusedmeetings <strong>with</strong> biomedical and clinical scientists alsotake place.Working <strong>with</strong> other specialtiesHaematologists work in joint clinics <strong>with</strong> clinicaloncologists, orthopaedic surgeons, obstetricians andpaediatricians depending on the relevant patient groupand may consult <strong>physicians</strong> from a number <strong>of</strong>disciplines when treating <strong>patients</strong> <strong>with</strong> complexhaematological disease. Close liaison <strong>with</strong> primary carespares many <strong>patients</strong> hospital visits and allowsmanagement in the community.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality service is dependent on evidence-basedmanagement, appropriate staffing and access toadequate facilities.Specialised facilitiesThe facilities required are dependent on the clinicalservice provided. For hospitals that care for <strong>patients</strong><strong>with</strong> haematological cancers, facilities should beorganised as set out in the document Improvingoutcomes in haematological cancers. 3 Specialist unitsmay require facilities for therapeutic apheresis andcytopheresis. Hospitals that deliver intrathecalchemotherapy must have a designated clinical area inwhichthisisperformed. 6Out<strong>patients</strong>Facilities should guarantee a rapid turnaround <strong>of</strong> bloodresults and should have an appropriate environment inwhich to deliver sensitive information to <strong>patients</strong> andtheir families.Day careHaematology day-care areas are crucial for patientreview and the delivery <strong>of</strong> blood products, certainchemotherapy regimens and infusional treatments(bisphosphonates, intravenous iron, immunoglobulin,coagulation factors and monoclonal antibodies). Goodday-care facilities greatly relieve pressure on inpatientbeds and are more acceptable to <strong>patients</strong>.In<strong>patients</strong>The number <strong>of</strong> dedicated beds and isolation roomsneeded and the requirement for filtered air and positivepressure rooms depends on the level <strong>of</strong> inpatient care<strong>of</strong>fered, particularly the predicted length <strong>of</strong> neutropeniaand the degree <strong>of</strong> immunosuppression. Facilities shouldbe appropriate for the age <strong>of</strong> the <strong>patients</strong> as outlined byNICE. 7Units that provide a specialist service for <strong>patients</strong> <strong>with</strong>inherited bleeding disorders and haemoglobinopathiesshould have adequate day-care facilities for review andtreatment <strong>of</strong> <strong>patients</strong> and access to appropriateinpatient facilities.Workforce requirements: clinical and support staffThe haematology team <strong>of</strong> a district general hospital(DGH) should have the following members. It should include at least three whole-timeequivalent (WTE) consultant haematologists; theseshould work as part <strong>of</strong> a team that may cover morethan one site. There will be either a nurse consultant or a number<strong>of</strong> clinical nurse specialists that may havesubspecialist expertise in areas <strong>of</strong> blood transfusion,haemoglobinopathies, venous thromboembolicdisease, haemophilia or bone-marrowtransplantation. Outpatient facilities and staffing and in<strong>patients</strong>taffing should be as outlined in Table 2. The service should also include access to apharmacist <strong>with</strong> a special interest in chemotherapy,a data manager, specialist palliative care, a dieticianand physiotherapists.Service developments to deliver improvedpatient careHaematologists maintain and improve quality <strong>of</strong> carefor their <strong>patients</strong> and the laboratory duties for which130 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Haematologythey have responsibility through involvement inmanagement, clinical governance, pr<strong>of</strong>essionalself-regulation, continuing pr<strong>of</strong>essional development(CPD), education and training and the provision <strong>of</strong>specialist advice at local, regional and national levels.They participate in national laboratory qualityassurance schemes; national service accreditationschemes such as that organised by Clinical PathologyAccreditation (UK) Ltd and the cancer peer-reviewprocess; projects to audit clinical outcomes andprocesses; and local, regional and national educationalmeetings.Research – clinical studies and basic scienceAlthough there are many challenges in academicmedicine haematology remains one <strong>of</strong> the moreacademic specialties. Most hospitals participate inclinical trials in accordance <strong>with</strong> the trust’s researchgovernance arrangements. Between 30–40% <strong>of</strong> traineestake time out during their higher specialist training t<strong>of</strong>ollow a research project, <strong>with</strong> many proceeding to ahigher degree. This research expertise is reflected in theenthusiastic support given to national studies organisedthrough the National Cancer Research Institute.Specialty and national guidelinesIn all areas <strong>of</strong> haematology, the BCSH produces robust,evidence-based guidance that meets the challenges <strong>of</strong> ahighly complex and rapidly changing field. Theguidelines are produced through a well-defined processdesigned to fully assess available evidence and involve allrelevant stakeholders. Guidelines are disseminated bypublication in peer-reviewed journals and on thewebsite <strong>of</strong> the BCSH (www.bcshguidelines.com), whichcurrently receives around 100,000 page hits per month.Other important guidelines include those forhaemophilia produced by UKHCDO, which is part <strong>of</strong>the Haemophilia Alliance(www.haemophiliaalliance.org.uk/docs/who.htm),those for blood transfusion produced by the NationalBlood Transfusion and Tissue Transplantation Service(www.transfusionguidelines.org.uk)andNICE(www.nice.org.uk).6 Clinical work <strong>of</strong> consultantsContributions made to acute medicalor surgical careHaematologists are consulted regularly on problemsarising as emergencies in acute medical and surgical<strong>patients</strong>, particularly <strong>with</strong> regard to haemostaticproblems and anticoagulant treatment.Direct clinical haematology careTable 3 outlines maximum clinical workload forconsultant haematologists according to the <strong>Royal</strong><strong>College</strong> <strong>of</strong> Physicians (RCP), and the data from 2005–6survey by the British Society for Haematology (BSH)and <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Pathologists (RCPath). 8Inpatient workThe type <strong>of</strong> work carried out by a consultanthaematologist varies considerably, depending onsubspecialisation and the size <strong>of</strong> the hospital, but almostall will have <strong>patients</strong> <strong>with</strong> complex medical conditionsthat make clinical responsibilities onerous. Time mustbe designated for MDTs to direct patient care. Theincreasing inexperience <strong>of</strong> trainees makes them less ableto contribute to the clinical service, and this isinfluencing a change from a consultant-led service to aconsultant-delivered service.Day-case and outpatient workMost haematologists run two to three outpatient clinicsper week and increasingly provide care in day caserather than inpatient settings.Specialist investigative and therapeuticproceduresBone marrow aspirates and trephine biopsies are usuallyperformed by medical staff, but nurses are increasinglybeing trained in the procedure. The results are reportedby haematologists, although the results <strong>of</strong> trephinebiopsies may be reported by a specialisthaemato-oncological pathologist.Intrathecal chemotherapy is given by specificallydesignated haematologists under strictly controlledconditions. 6 Apheresis is usually performed by specialistnurses under the supervision <strong>of</strong> a consultanthaematologist <strong>with</strong> experience in this field.Specialist on-call arrangementsHaematologists provide an essentiallyconsultant-delivered on-call service for their laboratorywork and for <strong>patients</strong> under their care, and aconsultative service to other disciplines. The intensity <strong>of</strong>on-call work varies (average on-call rota: one day inevery four days), 1 and provision <strong>of</strong> highly specialisedadvice can be onerous, particularly in transplant andhaemostasis centres.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 131


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 3 Recommended maximum clinical workload for consultant haematologists according to the <strong>Royal</strong> <strong>College</strong><strong>of</strong> Physicians (RCP) and data from 2005–6 survey 8Annual numbers <strong>of</strong> <strong>patients</strong>Activity RCP recommendation 2005–6 survey Difference (%)In<strong>patients</strong> 250Out<strong>patients</strong>New 250 211 –15.6Return 1,500 1,920 +28Day cases/ward attendees 1,500 1,180 –21 ∗Ward consults 100∗ Increasing by 10% per annum.Patients receiving OACs as out<strong>patients</strong> not included.Published figures from a haematology workforce document show that haematologists meet or exceed the RCP’s recommended outpatient numbers. 9Other specialist activity, including activitiesbeyond the local servicesReference laboratoriesSome highly specialised laboratories provide a regionalor even national service.Blood transfusionAppropriate time should be designated for theconsultant haematologist <strong>with</strong> responsibility for thehospital transfusion service to guarantee the safedelivery <strong>of</strong> this service. The team should include amember <strong>of</strong> the hospital transfusion team, together <strong>with</strong>a SPOT and the senior BMS <strong>of</strong> the hospital blood bank.This team is responsible for meeting the standardsoutlined in Better blood transfusion: safe and appropriateuse <strong>of</strong> blood 10 and Blood safety and quality regulations2005. 11 The team is also responsible for ensuring thatappropriate policies and guidelines are in place,including maximum blood ordering schedules (MBOS),emergency blood contingency and major incidentplanning, and that all blood components can be tracedfrom donor to recipient, <strong>with</strong> a 30-year audit trial keptas per the European directive on haemovigilance 2005. 12Hospital and primary care liaison activity<strong>Consultant</strong> haematologists are consulted regularly aboutthe management <strong>of</strong> <strong>patients</strong> in all specialties, particularlyabout problems related to anticoagulation. Many <strong>of</strong> theseconsultations may be dealt <strong>with</strong> on the telephone, butthe consultant frequently needs to see the patient. GPsappreciate close contact <strong>with</strong> haematology consultants:30–50% <strong>of</strong> laboratory work typically comes fromprimary care and telephone consultations are frequent.Roles in the laboratoryAbnormal blood films from general practice andhospitals and authorisation <strong>of</strong> all results are revieweddaily, and the workload is shared between members <strong>of</strong>the consultant haematology team. This frequently leadsto urgent primary care or intrahospital referrals.Clinical and laboratory networksMeetings <strong>of</strong> the MDT and other specialist meetings areheld in order to maintain clinical net<strong>working</strong> for themanagement <strong>of</strong> <strong>patients</strong>. The MDT meeting and regular‘handovers’ ensure safe continuity <strong>of</strong> care. Thedevelopment <strong>of</strong> pathology laboratory networks mayalso mean that the consultant haematologist isresponsible for an area <strong>of</strong> laboratory work acrossdifferent locations. The impact <strong>of</strong> the Carter report 13 onthe modernisation <strong>of</strong> pathology services will emerge inthenextfewyears,butitislikelythattheindependentsector will play an increasing role. Although this mayreduce the technical laboratory workload, it will have alimited effect on specialist laboratory tests or theadvisory role <strong>of</strong> consultants.7 Opportunities for integrated careThere are a number <strong>of</strong> opportunities for integrated<strong>working</strong> <strong>with</strong> both primary care and palliative care.Patients who require monitoring <strong>of</strong> low-gradehaematological conditions such as early chroniclymphocytic leukaemia, monoclonal gammopathy andminor abnormalities <strong>of</strong> the blood count such asthrombocytopenia or neutropenia, can be managed in ajoint way between primary and secondary care.132 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties HaematologyTable 4 Specimen consultant job planActivity Workload Programmed activities (PAs)Direct clinical careDiagnostic laboratory work 2–3Ward rounds, ward referrals, MDT meetings 2–3Outpatient clinics 2–3Marrows and other specialist procedures 0–0.5Lead haematologist laboratory 0–1Lead haematologist transfusionLead haematologist venousthromboembolismOn-call and weekend workTotal direct clinical care (PAs)Supporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality<strong>of</strong> healthcareOther NHS responsibilitiesExternal dutiesOne haematologist would have this recognised injob planOne haematologist would have this recognised injob planThis should not exceed a 1:3 rota and carry an8% supplement; PAs for predictable orunpredictable on-call work should be recognisedin job plan – eg one PA on average per weekEducation and training, appraisal, departmentalmanagement and service development, auditand clinical governance, CPD and revalidation,researcheg medical director, clinical director, leadconsultant in specialty, clinical tutoreg work for deaneries, royal colleges, specialistsocieties, DH or other government bodies0–10–17.5 on average2.5 on averageLocal agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trustNote: consultants <strong>with</strong> a significant academic workload will have separate PAs identified for NHS and/or university components. <strong>Consultant</strong> job plansmust take into account the European Working Time Directive (EWTD).Outreach haematology clinics have been established incommunity hospitals in conjunction <strong>with</strong> palliativecare. This allows for care to be delivered closer to thepatient’s home and can include simple palliativeinterventions such as supportive blood transfusions innon-haematology <strong>patients</strong> <strong>with</strong> advanced cancer whereappropriate.8 Workforce requirements for the specialtyCurrent workforce numbersAccording to the Information Centre’s 2009 census,there are 647 WTE consultants (700 headcount) whilethe Electronic Staff Record (ESR) from September 2009shows 580 WTE (605 headcount). 14The consultant workforce has increased by 11% duringthelastfiveyears. 15 The RCP’s census <strong>of</strong> consultant<strong>physicians</strong> in the UK in 2009 showed thathaematologists are on average contracted to work 11programmed activities (PAs) <strong>with</strong> the actual number <strong>of</strong>PAs delivered being 12.2. 15National consultant workforce requirementsThe Centre for Workforce Intelligence estimates that theexpected requirements based on changingdemographics indicate a required growth rate inconsultant haematologists <strong>of</strong> about 2%. 14,16 However,there are other factors that also need to be taken intoaccount when planning the future need for consultanthaematologists.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 133


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>As was outlined in the 2008 report published by theBSH and the RCPath, there are a number <strong>of</strong> pr<strong>of</strong>essionalissues that should be considered. 8 These include theincreasing complexity <strong>of</strong> treatment andsubspecialisation in haematology and other disciplines,the increasing impact <strong>of</strong> regulatory initiatives (egimproving outcome guidance and waiting-time targets)and legislation, as well as multidisciplinary <strong>working</strong> andinterhospital net<strong>working</strong>. Implementation <strong>of</strong> thedemands <strong>of</strong> Better blood transfusion: safe andappropriate use <strong>of</strong> blood 10 and the European directive onhaemovigilance 12 will require an additional 30–40consultants. An increasing laboratory workload (>5%increase per annum) generates increasing numbers <strong>of</strong>patient referrals and the need for clinical guidance onthe use <strong>of</strong> the laboratory and the interpretation <strong>of</strong>results. The specialty has supported improvements intraining programmes, but these too place greaterdemands on consultants’ and trainees’ time.The RCP report on the impact on medicine <strong>of</strong> theincreasing proportion <strong>of</strong> women entering the pr<strong>of</strong>essionidentified that haematology is one <strong>of</strong> the specialties thathas attracted a higher proportion <strong>of</strong> women. 17 As aresult, the current male:female ratio for consultantsover the age <strong>of</strong> 55 <strong>of</strong> 7:3 changes to 1:1 for youngerconsultants and for trainees it is 4:6. Since the male t<strong>of</strong>emale ratio <strong>of</strong> consultants that work less than full timein haematology is 1:4, an increasing number <strong>of</strong>consultant haematologists would be expected to workless than full time. In addition, the report also notedthat women who take career breaks are taking themlater in their medical careers as consultants, which isanother factor that will impact on the ability <strong>of</strong> aconsultant-delivered service to be maintained.Therefore, the pr<strong>of</strong>essional bodies recommend that thetotal number <strong>of</strong> consultant haematologists that will berequired is estimated to be 1250 (headcount).9 <strong>Consultant</strong> work programme/specimenjob planTable 4 outlines the typical work programme <strong>of</strong> aconsultant haematologist.10 Key points for commissioners1 Haematology is an integrated clinical and laboratoryspecialty; commissioning for one aspect <strong>of</strong> thespecialty <strong>with</strong>out consideration for the other mayimpact on the viability <strong>of</strong> a local service.2 Haematologists have a key role in providing adviceto other specialties <strong>with</strong>in a hospital as well as GPson both clinical and laboratory issues.3 Many aspects <strong>of</strong> a haematology service are nowprovided across a network that covers more than oneNHS provider and commissioners need to bear thisin mind when commissioning haematology services.4 Postgraduate training is closely linked to the currentorganisation <strong>of</strong> haematology services, another factorthat commissioners should bear in mind whencommissioning clinical and laboratory services.References1 Keele University. National Pathology Alliancebenchmarking review 2009–10. Keele: Keele University,2010.2 British Committee for Standards in Haematology.Facilities for the care <strong>of</strong> adult <strong>patients</strong> <strong>with</strong> haematologicalmalignancies – ‘levels <strong>of</strong> care’. BCSH Haemato-oncologyTask Force 2009. www.bcshguidelines.com/documents/levels<strong>of</strong>care 042010.pdf3 National Institute for Health and Care Excellence.Guidance on cancer services. Improving outcomes inhaematological cancers. The manual. London: NICE,2003.4 Fellows C. Analysis <strong>of</strong> frequent users, by local authority,April 2002–March 2003. London: London HealthObservatory, 2005. www.lho.org.uk/viewResource.aspx?id=97365 H<strong>of</strong>manD. Analysis <strong>of</strong> frequent hospital users, by PCT,April 2003–March 2004. London: London HealthObservatory, 2006. www.lho.org.uk/viewResource.aspx?id=102866 Department <strong>of</strong> Health. Updated national guidance on thesafe administration <strong>of</strong> intrathecal chemotherapy (HSC2008/001). London: DH, 2008.7 National Institute for Health and Care Excellence.Guidance on cancer services. Improving outcomes inchildren and young people <strong>with</strong> cancer. The manual.London: NICE, 2005.8 The British Society for Haematology and the <strong>Royal</strong><strong>College</strong> <strong>of</strong> Pathologists. Haematology consultantworkforce: the next 10 years. London: RCPath, 2008.9 Department <strong>of</strong> Health. The NHS cancer plan:aplanforinvestment,aplanforreform. London: DH, 2000.www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH 409813910 Department <strong>of</strong> Health. Better blood transfusion: safe andappropriate use <strong>of</strong> blood (HSC 2007/001). London: DH,2007.134 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Haematology11 Department <strong>of</strong> Health. The blood safety and qualityregulations 2005. London: Stationery Office, 2005.12 Directive 2005/61/EC <strong>of</strong> the European Parliament andCouncil.13 Lord Carter <strong>of</strong> Coles. Report <strong>of</strong> the second phase <strong>of</strong> thereview <strong>of</strong> NHS pathology services in England.London:DH, 2008.14 Centre for Workforce Intelligence. Medical specialtyworkforce factsheet – haematology. CfWI, August 2010.15 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> theUnited Kingdom. Census <strong>of</strong> consultant <strong>physicians</strong> andmedical registrars in the UK, 2009: data and commentary.London: RCP, 2010.16 Centre for Workforce Intelligence. Recommendation forhaematology training 2011. CfWI, August 2010.17 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Elston MA. Women andmedicine. The future. London: RCP, 2009.Note to readers: This chapter has been reproduced from the book’s 5th edition (2011) as the author felt it did not need updating for the 2013 revision.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 135


2 Specialties ImmunologyImmunologySiraj A Misbah MBBS MSc FRCP FRCPath <strong>Consultant</strong> clinical immunologist1 Description <strong>of</strong> the specialtyThe clinical practice <strong>of</strong> immunology, as defined by theWorld Health Organization (WHO), encompasses theclinical and laboratory activity dealing <strong>with</strong> the study,diagnosis and management <strong>of</strong> <strong>patients</strong> <strong>with</strong> diseasesresulting from disordered immunological mechanismsand conditions in which immunological manipulationsform an important part <strong>of</strong> the therapy. 1 In the UK, thepractice <strong>of</strong> immunology largely conforms to this WHOdefinition, <strong>with</strong> immunologists providing combinedclinical and laboratory services for <strong>patients</strong> <strong>with</strong>immunodeficiency, autoimmune disease, systemicvasculitis and allergy.Following the recent re-organisation <strong>of</strong> the NHS,specialist immunology and allergy services will benationally commissioned for <strong>patients</strong> <strong>with</strong>immunodeficiency, C1 inhibitor deficiency andcomplex allergy. To underpin this initiative, newservice specifications have been produced to ensureequitable delivery <strong>of</strong> high-quality networked servicesnationally.Who are the <strong>patients</strong>?Patients <strong>with</strong> immunologically mediated diseasescomprise a diverse group who present to a variety <strong>of</strong>medical specialties. Within this group, <strong>patients</strong> <strong>with</strong>primary immunodeficiency disorders (PIDs) haveparticular clinical needs given the relative rarity <strong>of</strong> theirchronic conditions and the attendant diagnostic delay,<strong>with</strong> the need for complex therapy and lifelongimmunological follow-up. 2 Such <strong>patients</strong> require accessto a specialist clinical immunology service for optimalcare. Patients <strong>with</strong> autoimmune disease, systemicvasculitis and serious allergy require access to therelevant organ-based specialty <strong>working</strong> in partnership<strong>with</strong> a high-quality immunology laboratory to ensureprompt diagnosis and optimal management <strong>of</strong> theirconditions.Although allergy is recognised as a specialty in its ownright, the immunology curriculum includes allergy asan important component and produces immunologistsequipped <strong>with</strong> the requisite knowledge and skills toindependently investigate and manage <strong>patients</strong> <strong>with</strong>allergic diseases <strong>of</strong> all degrees <strong>of</strong> severity. In view <strong>of</strong> theimmunological principles underlying allergic diseaseand the patchy development <strong>of</strong> allergy services, mostimmunologists have established and continue toprovide a full range <strong>of</strong> specialist allergy servicesincluding desensitisation therapy. 3 Currently, clinicalimmunologists are the main providers <strong>of</strong> specialistallergyservicesinmostregions<strong>of</strong>theUK. 3 The poorprovision <strong>of</strong> allergy services in the NHS at presentunderlines the need for the urgent development <strong>of</strong>allergy networks comprising immunologists, specialistallergists and organ-based specialists <strong>with</strong> an interest inallergy.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceClinical immunology has evolved over the past twodecades from a laboratory base to a combined clinicaland laboratory specialty, <strong>with</strong> the immunologist’s roleas a physician becoming increasingly prominent. Atypical immunology service is based in a teachinghospital led by a consultant immunologist andcomprises a mixture <strong>of</strong> clinical and laboratory staff. Theclinical team will include specialty registrars (StRs) inimmunology and immunology nurse specialists, whilethe laboratory team is composed <strong>of</strong> healthcare scientists.Sources <strong>of</strong> referral from primary, secondary andtertiary levelsThe majority <strong>of</strong> referrals to immunologists involve<strong>patients</strong> <strong>with</strong> suspected immune deficiency, severeallergy, systemic autoimmune disease and vasculitis.Referrals emanate from colleagues in both hospital andprimary care.The advent <strong>of</strong> laboratory accreditation has led manydistrict general hospitals (DGHs) to seek formalC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 137


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>consultant immunology input into their diagnosticimmunology services. In many instances, laboratoryduties are combined <strong>with</strong> clinical work. In some parts <strong>of</strong>the country, this arrangement has enabled thedevelopment <strong>of</strong> a clinical network linking the regionalimmunology service to surrounding DGHs, thereforeensuring wider delivery <strong>of</strong> clinical immunology services.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong>Involving <strong>patients</strong> in decisions about theirtreatmentPatients <strong>with</strong> immunodeficiency disorders have alifelong need for specialist immunological care. As theirprimary <strong>physicians</strong>, immunologists work in closepartnership <strong>with</strong> colleagues from other disciplines toensure that their <strong>patients</strong>’ complex multisystemcomplications are managed optimally across disciplines.The coordination <strong>of</strong> multidisciplinary care byimmunologists for immunodeficient <strong>patients</strong> is a goodexample <strong>of</strong> the integrated care that these <strong>patients</strong>require. Patient empowerment has been enthusiasticallyembraced by immunologists as evidenced by thewidespread development <strong>of</strong> home immunoglobulininfusion programmes, which enable <strong>patients</strong> toself-infuse immunoglobulin at home followingcompletion <strong>of</strong> a competency-based trainingprogramme. The principle <strong>of</strong> home therapy has recentlybeen extended to include C1 inhibitor infusion inselected <strong>patients</strong> <strong>with</strong> hereditary angioedema due to C1inhibitor deficiency. 4,5 Both <strong>of</strong> these initiatives havebeen welcomed by <strong>patients</strong> and their support groups.Patient support groupsFollowing the recent dissolution <strong>of</strong> the PrimaryImmunodeficiency Association (PiA), new patientgroups have emerged to provide a vital source <strong>of</strong>educational and pastoral support for <strong>patients</strong>. Bothadult and paediatric immunologists serve on themedical advisory panel <strong>of</strong> the PiA and play animportant educational and advisory role in raisingawareness <strong>of</strong> immunodeficiencies among the widermedical pr<strong>of</strong>ession and policy makers. Immunologistsare also actively involved in patient education bymaking regular presentations to regional and nationalpatient meetings and contributing to patientnewsletters.The concept <strong>of</strong> the expert patient is particularlyapposite to <strong>patients</strong> <strong>with</strong> primary immunodeficiencywho have a lifetime’s experience <strong>of</strong> the problemsassociated <strong>with</strong> defective immunity. Actively obtaining<strong>patients</strong>’ views on the quality <strong>of</strong> the clinical serviceafforded to immunodeficient <strong>patients</strong> is a requirementfor accreditation <strong>of</strong> immunodeficiency services by theUnited Kingdom Primary Immunodeficiency Network(UKPIN). This is a multidisciplinary organisationcomprising clinicians, nurses and scientists. Regularmeetings between UKPIN and patient support groupsabout matters <strong>of</strong> mutual interest ensure that <strong>patients</strong>’views are well represented in both medical andindustrial forums. Topics range from the supply <strong>of</strong>therapeutic immunoglobulin, the relative risk <strong>of</strong> variantCreutzfeldt–Jakob disease (vCJD) from blood productsand research into PIDs. A further example <strong>of</strong> patientengagement is the active involvement <strong>of</strong> patientrepresentatives in the ongoing national demandmanagement plan <strong>of</strong> the Department <strong>of</strong> Health (DH) toensure that immunoglobulin usage is prioritised andtargeted at those <strong>patients</strong> who are in greatest need <strong>of</strong>immunoglobulin therapy. 64 Interspecialty and interdisciplinaryliaisonMultidisciplinary team <strong>working</strong>Immunologists work as members <strong>of</strong> multidisciplinaryteams (MDTs) that include nurse specialists andlaboratory healthcare scientists. Nurse specialists inimmunology play a leading role in all aspects <strong>of</strong>immunoglobulin infusion, from the supervision <strong>of</strong>hospital-based therapy to the training and supervision<strong>of</strong> <strong>patients</strong> who undertake self-infusion <strong>of</strong>immunoglobulin as part <strong>of</strong> the home therapyprogramme. In many centres, immunology nursespecialists undertake skin testing for allergy and train<strong>patients</strong> <strong>with</strong> life-threatening allergic disease in the use<strong>of</strong> self-injectable adrenaline. Some immunology nursespecialists have completed the extended prescribingcourse for nurses and have set up autonomousclinics for the diagnosis and management <strong>of</strong> allergicdiseases.Working <strong>with</strong> other specialtiesSeveral additional services are essential for the efficientdelivery <strong>of</strong> a good immunology service. Access tospecialist services such as microbiology, virology,cellular pathology and radiology are vital for the early138 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Immunologydetection and optimal management <strong>of</strong> thecomplications <strong>of</strong> immunodeficiency. Multidisciplinarymeetings provide education and improved liaison forpatient care. A comprehensive diagnostic immunologylaboratory underpins the diagnosis <strong>of</strong> allimmunological disease and is integral to the success <strong>of</strong> aclinical immunology service.Considering the propensity <strong>of</strong> antibody-deficient<strong>patients</strong> to develop complications involvingmultiple-organ systems, immunologists must liaiseclosely <strong>with</strong> colleagues in a range <strong>of</strong> specialtiesincluding: respiratory medicine; ear, nose and throat(ENT) surgery; haematology; ophthalmology; andgastroenterology.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality clinical immunology service willbe consultant led and adequately staffed (medical,scientific, nursing and secretarial), <strong>with</strong>appropriate resources to support service delivery.It must be supported by an accredited immunologylaboratory providing a full repertoire <strong>of</strong>investigations encompassing immunochemistry,autoimmunity, allergy, and cellular and molecularimmunology.Maintaining and improving the quality<strong>of</strong> careThe DH in England has published specialiseddefinitions for clinical immunology (definition no. 16)and allergy (definition no. 15). The previous set <strong>of</strong>definitions encompassed a definition for specialisedpathology diagnostic services, including immunology(definition no. 25). Although the last has not beenrevised, collectively, these definitions provide abenchmark for the practice <strong>of</strong> immunology. 7,8 Thequality <strong>of</strong> the laboratory immunology service hasbeen underpinned by Clinical Pathology Accreditation(UK) Ltd (CPA) since 1993. This accreditation processis now encompassed <strong>with</strong>in the remit <strong>of</strong> the UnitedKingdom Accreditation Service (UKAS). Enrolment<strong>with</strong> the CPA was made a mandatory requirement bythe DH for all laboratory disciplines in 2003. Many unitsacross the UK are now developing laboratory servicespecifications <strong>with</strong> key performance indicators aspart <strong>of</strong> the DH’s ‘modernising pathology services’initiative.Service developments to deliver improved careThe process <strong>of</strong> accreditation <strong>of</strong> clinical immunologyservices for immunodeficiency through a system <strong>of</strong> peerreview by UKPIN is actively under way. Participation inboth clinical and laboratory accreditation ensures thatimmunology services comply <strong>with</strong> current standards <strong>of</strong>clinical governance. Evidence <strong>of</strong> active participation inaudit is an essential prerequisite for accreditation inboth clinical and laboratory immunology. Recentexamples <strong>of</strong> audits that have influenced practice includean audit <strong>of</strong> a gating policy for requesting antineutrophilcytoplasmic antibodies 9 and an on-going audit <strong>of</strong> thediagnosis and management <strong>of</strong> C1 inhibitor deficiency.UKPIN fulfils an important educational role in thedevelopment <strong>of</strong> guidelines on the diagnosis andmanagement <strong>of</strong> immunodeficiencies(www.ukpin.org.uk). The network also develops theimmunodeficiency register and works closely <strong>with</strong>governmental agencies involved in the provision <strong>of</strong>therapeutic agents for patient care.In view <strong>of</strong> the patchy provision <strong>of</strong> allergy services,immunologists are actively involved in developingaccreditation standards for allergy under theauspices <strong>of</strong> the Joint Committee on Immunologyand Allergy (<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP) and<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Pathologists (RCPath)). The increasingrecognition <strong>of</strong> anaesthetic allergy has promptedimmunologists and allergists to work closely <strong>with</strong> theAssociation <strong>of</strong> Anaesthetists <strong>of</strong> Great Britain andIreland to develop guidelines for the investigation <strong>of</strong><strong>patients</strong> who develop perioperative anaphylaxis. 10This initiative has been successful in improvingreferral pathways and ensuring that these <strong>patients</strong> areprovided <strong>with</strong> a clear management plan for futureanaesthesia.Immunologists positively embrace service developmentsand initiatives that deliver improved patient care, egtraining <strong>patients</strong> to use home immunoglobulin therapythrough intravenous or subcutaneous routes. Homeintravenous immunoglobulin (IVIg) therapy, initiallydeveloped for <strong>patients</strong> <strong>with</strong> primary antibodydeficiency, has now been extended in some centresto <strong>patients</strong> <strong>with</strong> autoimmune neuropathies in whomit is used as maintenance immunomodulatorytherapy.In the laboratory, immunologists take a lead role in theassessment <strong>of</strong> new diagnostic tests for immunologicaldiseases, followed, if appropriate, by their introductioninto routine clinical practice.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 139


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Education and training, clinical governance andmanagement dutiesImmunologists are actively involved in a range <strong>of</strong> dutiesthat are essential to the maintenance <strong>of</strong> high standards<strong>of</strong> clinical practice. These include: education andtraining <strong>of</strong> StRs, laboratory scientists and nurses;continuing pr<strong>of</strong>essional development (CPD); clinicalgovernance; General Medical Council (GMC)revalidation; local management and national work forthe RCP and RCPath and specialist immunologicalsocieties – the British Society for Immunology (BSI),the British Society for Allergy and Clinical Immunology(BSACI) and UKPIN. With the development <strong>of</strong> acompetency-based curriculum in immunology, it isenvisaged that a consultant <strong>with</strong> responsibilities as aneducational supervisor will need to devote one weeklyprogrammed activity (PA) to teaching and trainingactivities.Research – clinical studies and basic scienceThe direct relevance <strong>of</strong> immunology to much <strong>of</strong> clinicalmedicine and its strong scientific foundations provideample opportunities for clinical studies <strong>of</strong> newimmunomodulatory therapies, the recognition <strong>of</strong> newdiseases (as shown by recent descriptions <strong>of</strong> new forms<strong>of</strong> severe combined immunodeficiency and type 1cytokine deficiency) and translational research. Despitetheir heavy NHS commitments, many immunologistsare actively involved in national and internationalclinical and laboratory studies.The few full-time academic immunologists make aproportionately greater contribution to research whileshouldering a significant clinical workload for the NHS.With the disappearance <strong>of</strong> many university immunologydepartments and recent medical school expansion,consultant immunologists have major undergraduateand postgraduate teaching commitments.6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialtyThe clinical work <strong>of</strong> consultant immunologists is largelyoutpatient based, <strong>with</strong> the following broad workpatterns: Immunologists are solely responsible for <strong>patients</strong><strong>with</strong> primary immunodeficiencies (antibodydeficiency, combined T- and B-cell deficiency,complement deficiency and phagocytic defects). In many centres, consultant immunologists areresponsible for <strong>patients</strong> <strong>with</strong> complex, severe allergicdisease (food allergy, drug allergy, venom allergy andanaphylaxis). In most centres, consultant immunologists performjoint clinics <strong>with</strong> paediatricians to care for children<strong>with</strong> immunodeficiencies and allergy. Many immunologists have an interest in connectivetissue disease and perform joint clinics <strong>with</strong>rheumatologists for <strong>patients</strong> <strong>with</strong> autoimmunerheumatic disease and systemic vasculitis. Theincreasing recognition <strong>of</strong> autoinflammatorydisorders and its inclusion in the nationalcommissioning specification for immunodeficiency,reflects the key role played by immunologists ininvestigating and managing these <strong>patients</strong>, eithersingly or jointly <strong>with</strong> rheumatologists. Day-case immunoglobulin infusion clinics for<strong>patients</strong> <strong>with</strong> antibody deficiency form an integralpart <strong>of</strong> the clinical workload <strong>of</strong> consultantimmunologists. With increasing recognition <strong>of</strong> IVIgas a therapeutic immunomodulator, these infusionclinics have expanded in some centres to includenon-antibody-deficient <strong>patients</strong>, eg those <strong>with</strong>inflammatory neuropathies. Immunologists are increasingly involved in thesupervision <strong>of</strong> <strong>patients</strong> receiving therapeuticbiologics for systemic autoimmune disease. Theimmunology laboratory plays a key role inmonitoring the response to certain biologics asexemplified by B-cell quantification in <strong>patients</strong>receiving rituximab (an anti-CD20 monoclonalantibody). Many laboratories have led theintroduction <strong>of</strong> interferon-γ assays to detect latenttuberculosis as part <strong>of</strong> the pretreatment assessment<strong>of</strong> <strong>patients</strong> receiving anti-tumour necrosis factor(TNF)-based therapies.Outpatient workOutpatient work includes the following: primary immunodeficiency clinics severe allergic disease clinics day-case desensitisation immunotherapy challenge clinics for drug and food allergy combined clinics <strong>with</strong> paediatricians for children<strong>with</strong> immunodeficiency and allergy combined clinics <strong>with</strong> rheumatologists supervision <strong>of</strong> day-case immunoglobulin infusionclinics for antibody replacement and therapeuticimmunomodulation140 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Immunology supervision <strong>of</strong> day-case clinics for infusion <strong>of</strong>therapeutic antibodies (biologics) transition clinics for adolescents <strong>with</strong> primaryimmunodeficiency as they move from paediatric toadult services.The complexity <strong>of</strong> clinical referrals requires thatsufficient time is given to the assessment <strong>of</strong> <strong>patients</strong> atthe first consultation, which limits the number <strong>of</strong><strong>patients</strong> who can be seen in a single outpatient session.A consultant immunologist <strong>working</strong> alone will typicallysee 5–10 (new and follow-up) <strong>patients</strong> in a singlesession, depending on the complexity <strong>of</strong> the <strong>patients</strong>’problems. An audit <strong>of</strong> primary antibody deficiency, andguidelines from UKPIN, suggest that a consultantshould be responsible for up to 100 <strong>patients</strong> <strong>with</strong>antibody deficiency in order to deliver optimum care. 11Specialist investigative procedures<strong>Consultant</strong> immunologists are responsible for directingdiagnostic immunology services and perform a widerange <strong>of</strong> duties including clinical liaison, interpretationand validation <strong>of</strong> results, quality assurance, assaydevelopment, and supervision <strong>of</strong> biomedical andclinical scientists and StRs. Some consultants perform alimited amount <strong>of</strong> ‘hands-on’ laboratory work.In view <strong>of</strong> the work pressures on immunologists, CPAguidelines stipulate that a single consultantimmunologist should not support more than twolaboratories outside their base hospital at any one timeand the weekly <strong>of</strong>f-site commitment to these should notbe more than two PAs (including travelling time).Driven by advances in laboratory technology and there-appraisal <strong>of</strong> the role <strong>of</strong> the physician in laboratorymedicine, 12 there is an increasing trend for integration<strong>of</strong> significant parts <strong>of</strong> the conventional immunology testrepertoire in to multidisciplinary blood science or coreautomated laboratories. This initiative coupled <strong>with</strong>reconfiguration <strong>of</strong> pathology laboratories in line <strong>with</strong>the Carter review 13 is likely to impact on the futurework patterns <strong>of</strong> immunologists by changing thebalance between laboratory and clinical activities.Specialist on callThe nature <strong>of</strong> on-call duties in immunology only rarelywarrants the out-<strong>of</strong>-hours attendance <strong>of</strong> consultantimmunologists. However, it is important that an on-callspecialist immunology service is available for thediscussion <strong>of</strong> clinical problems and emergencylaboratory investigations. The frequency <strong>of</strong> on-callduties for consultant immunologists will be determinedby the number <strong>of</strong> colleagues in a centre. Where possible,an on-call rota <strong>with</strong> a frequency <strong>of</strong> one in two or one inthree is recommended, although it is recognised thatconsultants who work single-handedly will havedifficulty <strong>with</strong> this arrangement. In such cases, thepossibility <strong>of</strong> forming a consortium <strong>with</strong> colleagues inadjacent regions to provide an acceptable level <strong>of</strong> covershould be explored.7 Opportunities for integrated careThe frequent requirement for multidisciplinary care forimmunodeficient <strong>patients</strong> who develop organ-specificcomplications has prompted immunologists to embraceenthusiastically the principles <strong>of</strong> integrated care acrossspecialties. The adoption <strong>of</strong> UKPIN accreditationstandards by many immunology centres has driven thedevelopment <strong>of</strong> protocols ensuring clear documentation<strong>of</strong> the clinical process and evidence-based managementguidelines underpinning the provision <strong>of</strong> integratedcare to <strong>patients</strong> <strong>with</strong> immunodeficiency.Participation in multidisciplinary clinics and/or teammeetings for <strong>patients</strong> <strong>with</strong> systemic autoimmunediseases and vasculitis are further examples <strong>of</strong>integrated care. Similarly, the principles <strong>of</strong> integratedcare have been applied to the investigation andfollow-up <strong>of</strong> <strong>patients</strong> <strong>with</strong> anaphylaxis followingattendance at accident and emergency departments.8 Workforce requirements for the specialtyCurrently, 60 consultant immunologists serve the entirepopulation <strong>of</strong> England and Wales.Limited data are available on the workload <strong>of</strong>immunologists, who are based mainly in teachinghospitals. Increasing awareness <strong>of</strong> immunologicaldiseases, coupled <strong>with</strong> the need to provide specialistadvice and direction to immunology laboratories,including those in larger DGHs, has placed atraditionally understaffed specialty <strong>with</strong> manyconsultants who work single-handedly under greatstrain.An estimate <strong>of</strong> the number <strong>of</strong> consultant immunologistsrequired in England and Wales is based upon the lastworkload survey undertaken by the RCPath, the RCPcensus and extensive consultation <strong>with</strong>in theC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 141


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 <strong>Consultant</strong> work programme/specimen job planActivity Workload Programmed activities (PAs)Direct clinical careOutpatient clinics 5–10 <strong>patients</strong> per clinic 3–4New <strong>patients</strong>Follow-up <strong>patients</strong>IVIg infusion2–4 <strong>patients</strong> per clinic3–6 <strong>patients</strong> per clinic6–10 <strong>patients</strong> per clinicWard consultation and telephone advice 0.5Allergy, including desensitisation immunotherapy 1Laboratory workClinical liaison, interpretation <strong>of</strong> resultsQuality assuranceAssay developmentHands-on laboratory workSupervision <strong>of</strong> DGH immunology laboratoriesTotal laboratory work 3–4Total number <strong>of</strong> direct clinical care PAs7.5 on averageSupporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong>healthcareOther NHS responsibilitiesExternal dutiesEducation and training, appraisal,departmental management and servicedevelopment, audit and clinicalgovernance, CPD and revalidation,researcheg medical director, clinical director, leadconsultant in specialty, clinical tutoreg work for deaneries, royal colleges,specialist societies, DH or othergovernment bodies2.5 on averageLocal agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trustspecialty. 14,15 The latest RCP census showed thatimmunologists worked an average <strong>of</strong> 12.5 PAs per week.This represents an excess <strong>of</strong> 10.8 hours worked abovecontractual obligations.Workforce requirements have been calculated on thebasis that most immunologists are based in teachinghospitals and the population served by existingconsultant immunologists is approximately40 million.Because there are insufficient data on immunologyworkload at DGH level, it is not possible to calculateworkforce requirements for a 250,000 population.Instead, the projected estimates are based on theassumption that each consultant will not be expected toexceed their contractual obligation <strong>of</strong> 10 PAs and noconsultant will have to practise on his or her own(currently 13% <strong>of</strong> consultant immunologists work ontheir own).On this basis, it is estimated that 105 whole-timeequivalent (WTE) consultants in immunology arerequired to serve the population <strong>of</strong> England and Wales(54 million). This translates into one consultantimmunologist per 514,285 population compared <strong>with</strong>the existing provision <strong>of</strong> one per 0.9 million population.This is 0.31 WTE for 250,000 population, which is an142 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Immunologyexpansion <strong>of</strong> 75%. In addition to replacing retiringconsultants, numbers will need to expand by 7.5% perannum over the next 10 years to achieve this figure.9 <strong>Consultant</strong> work programme/specimenjob planTable 1 shows a consultant work programme/specimenjob plan.10 Key points for commissioners1 Immunology and allergy services for <strong>patients</strong> <strong>with</strong>primary immunodeficiency, complex allergy andC1 inhibitor deficiency have been designated asnationally commissioned services.2 The specialty deals <strong>with</strong> many rareimmunodeficiency disorders that have designated‘orphan status’ <strong>with</strong>in the European Union.3 Specialist management for <strong>patients</strong> <strong>with</strong> primaryantibody deficiency is highlighted by theimprovements in actuarial survival and reductionsin morbidity that have accrued as a direct result <strong>of</strong><strong>patients</strong> receiving dedicated care fromimmunologists. 16,174 Evidence-based guidelines for the management <strong>of</strong><strong>patients</strong> <strong>with</strong> primary antibody deficiency havebeen developed by UKPIN (including guidance forcommissioners) and, as major users,immunologists have played a key role in thedevelopment and implementation <strong>of</strong> the DH’simmunoglobulin demand management plan.5 The use <strong>of</strong> therapeutic immunoglobulin forantibody deficiency and immunomodulation isunderpinned by a number <strong>of</strong> key performanceindicators (KPIs), which will be monitored as part<strong>of</strong> a national dashboard.6 Patients <strong>with</strong> C1 inhibitor deficiency (hereditaryand acquired) are dependent on emergencytreatment <strong>with</strong> C1 inhibitor and/or bradykininreceptor antagonists (Icatibant) for crises, <strong>with</strong> aminority requiring prophylactic treatment. As <strong>with</strong>antibody deficiency, these <strong>patients</strong> should bemanaged in centres <strong>with</strong> appropriate specialistimmunological expertise.7 Immunologists have led the development <strong>of</strong> hometherapy for <strong>patients</strong> <strong>with</strong> antibody deficiency(immunoglobulin), autoimmune neuropathies andhereditary angioedema (C1 inhibitor).8 Immunologists are major providers <strong>of</strong>comprehensive allergy services and are closelyinvolved in the development <strong>of</strong> accreditationstandards for allergy centres.9 The need for, and evidence supporting, growth inthe capacity <strong>of</strong> specialised allergy services has beenmade repeatedly in recommendations (2003–2010)from the medical royal colleges, the House <strong>of</strong>Commons Health Select Committee and the House<strong>of</strong> Lords Science and Technology Committee.10 Specialised immunology diagnostic laboratoryservices should only be commissioned fromaccredited laboratories.References1 Lambert PH, Metzger H, Miyamoto T, et al. Clinicalimmunology: guidelines for its organization, trainingand certification. Relationships <strong>with</strong> allergology andother medical disciplines. A WHO/IUIS/IAACI report.Clin Exp Immunol 1993;93:484–91.2 Wood P, Stanworth S, Burton J, et al. UK PrimaryImmunodeficiency Network. Recognition, clinicaldiagnosis and management <strong>of</strong> <strong>patients</strong> <strong>with</strong> primaryantibody deficiencies: a systematic review. Clin ExpImmunol 2007;149:410–23.3 El-Shanawany TM, Arnold H, Carne E, et al. Survey <strong>of</strong>clinical allergy services provided by clinicalimmunologists in the UK. J Clin Pathol 2005;58:1283–90.4 Longhurst HJ, Carr S, Khair K. C1-inhibitor concentratehome therapy for hereditary angioedema: a viable,effective treatment option. Clin Exp Immunol2007;147:11–17.5 Gompels MM, Lock RJ, Abinun M, et al. C1 inhibitordeficiency: consensus document. Clin Exp Immunol2005;139:379–94.6 Provan D, Chapel HM, Sewell WAC, O’Shaughnessy D.Prescribing intravenous immunoglobulin: summary <strong>of</strong>Department <strong>of</strong> Health guidelines (on behalf <strong>of</strong> the UKImmunoglobulin Expert Working Group). BMJ2008;337:990–2.7 Department <strong>of</strong> Health. Specialised services nationaldefinitions set: 3rd edn. Specialised immunology services(all ages). Definition no 16. London: DH, 2008.8 Department <strong>of</strong> Health. Specialised services nationaldefinition set, 2nd edn. Specialised pathology services (allages). Definition no. 25. London: DH, 2002.9 Arnold DF, Timms A, Luqmani R, Misbah SA. Does agating policy for ANCA overlook <strong>patients</strong> <strong>with</strong> ANCAassociated vasculitis? An audit <strong>of</strong> 263 <strong>patients</strong>. JClinPathol 2010;63:678–80.10 Harper NJ, Dixon T, DuguéP,et al. Suspectedanaphylactic reactions associated <strong>with</strong> anaesthesia.Anaesthesia 2009;64:199–211.11 Spickett GP, Askew T, Chapel HM. Management <strong>of</strong>primary antibody deficiency by consultantC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 143


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>immunologists in the UK: a paradigm for other rarediseases. Qual Health Care 1995;4:263–8.12 Misbah SA, Kokkinou V, Jeffery K, et al. The role <strong>of</strong> thephysician in laboratory medicine: a Europeanperspective. JClinPathol2013 (In press).13 Department <strong>of</strong> Health. Independent review <strong>of</strong> NHSpathology services in England (Carter review). London:DH, 2010.14 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Pathologists. Medical and scientificstaffing <strong>of</strong> National Health Service pathology departments.London: RCPath, 1999.15 The Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> theUnited Kingdom. Census <strong>of</strong> consultant <strong>physicians</strong> andmedical registrars in the UK, 2011: data and commentary.London: RCP, 2013.16 Orange JS, Grossman WJ, Navickis RJ, Wilkes MM.Impact <strong>of</strong> trough IgG on pneumonia incidence inprimary immunodeficiency: a meta-analysis <strong>of</strong> clinicalstudies. Clin Immunol 2010;137:21–30.17 Chapel H, Lucas M, Lee M, et al. Common variableimmunodeficiency disorders: division into distinctclinical phenotypes. Blood 2008;112:277–86.144 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Infectious diseases and tropical medicineInfectious diseases and tropical medicineChristopher P Conlon MA MD FRCP FRCPI <strong>Consultant</strong> in infectious diseases1 Description <strong>of</strong> the specialtyWhat is the specialty?Infectious diseases and tropical medicine as specialtiesencompass the diagnosis and management <strong>of</strong> a widevariety <strong>of</strong> infections, only some <strong>of</strong> which are ‘infectious’in the commonly understood sense <strong>of</strong> the word.Previously associated <strong>with</strong> fever hospitals, infectiousdiseases is now a specialty fully integrated into themodern general, acute hospital and closely allied <strong>with</strong>acute medical specialties. Physicians in the specialtyhelp hospitals deal <strong>with</strong> problems associated <strong>with</strong>healthcare-associated infections and, at the sametime, the specialty is at the forefront <strong>of</strong> efforts torecognise and contain emerging infections like severeacute respiratory syndrome (SARS) and avian influenza.The specialty is also involved in providing travelmedicine advice for those visiting the tropics and forassessing those travellers returning to the UK <strong>with</strong>health problems. Most infectious diseases <strong>physicians</strong> areactively engaged in research and other academicactivities.Who are the <strong>patients</strong>?Most in<strong>patients</strong> arrive from the community as acuteadmissions to infectious diseases wards. A variety <strong>of</strong>conditions, such as gastroenteritis, bacterialpneumonia, meningitis, skin and s<strong>of</strong>t tissue infectionsare managed in addition to more exotic conditions suchas HIV, malaria and tuberculosis. The <strong>patients</strong> <strong>with</strong>infectionsareadults<strong>of</strong>anyagebutaproportion<strong>of</strong>thesemay present <strong>with</strong> infections and end up <strong>with</strong> anon-infective diagnosis, such as connective tissuedisease or malignancy. Due to the nature <strong>of</strong> thespecialty, there are disproportionate numbers <strong>of</strong>vulnerable <strong>patients</strong>, such as asylum seekers and recentimmigrants, the homeless, prisoners, intravenous drugusers and visitors from the tropics.Main disease patternsIn addition to the workload provided bycommunity-acquired infections such as pneumonia,pyelonephritis and cellulitis, the specialty is increasinglyinvolved in managing the infective complications <strong>of</strong> agrowing number <strong>of</strong> immunosuppressed <strong>patients</strong>.Advances in cancer care and autoimmune diseases meanthat more <strong>patients</strong> survive but are prone to infections,many <strong>of</strong> which are unusual. Over the past two decadesHIV infections have increased. New <strong>patients</strong> continue topresent <strong>with</strong> infective complications <strong>of</strong> HIV and thosecan be complex to manage. In addition, the welcomesuccess <strong>of</strong> highly active antiretroviral therapy (HAART)has dramatically increased survival in HIV, so thenumber <strong>of</strong> <strong>patients</strong> seen in the clinics continues toincrease, putting pressure on services. Many infectiousdiseases <strong>physicians</strong> are managing increased numbers <strong>of</strong>hepatitis virus infected <strong>patients</strong> (hepatitis B and C). Atthe same time, increasing problems <strong>with</strong> antibioticresistance are changing the face <strong>of</strong> healthcare-associatedinfection. The specialty has to cope <strong>with</strong> the problems<strong>of</strong> methicillin-resistant Staphylococcus aureus (MRSA)and new strains <strong>of</strong> Clostridium difficile, aswellasmultiresistant urinary tract infections and resistanttuberculosis.Finally, increasing numbers <strong>of</strong> travellers from the UKand migrants to the UK increase the number <strong>of</strong> tropicalinfections, eg malaria, that are imported.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceMost infectious diseases units are associated <strong>with</strong>teaching hospitals but, increasingly, new units are beingestablished in larger district general hospitals (DGHs).Inpatient services are provided in the infectious diseasesward, which provides single rooms for isolationpurposes, some <strong>of</strong> which have negative pressureventilation systems to reduce the risk <strong>of</strong> transmission <strong>of</strong>respiratory pathogens, such as tuberculosis (TB). Theinfectious diseases ward takes in acute admissions24 hours a day. In addition, outpatient services aresufficiently flexible to see urgent out<strong>patients</strong>immediately, such as those returning from the tropics<strong>with</strong> fevers or HIV-positive <strong>patients</strong> <strong>with</strong> new problems.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 145


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>A significant part <strong>of</strong> the practice <strong>of</strong> an infectiousdiseases physician is to provide consultation advice forother specialists, ranging from general medicinethrough to surgery, obstetrics and gynaecology,neurology and intensive care. Infectious diseases<strong>physicians</strong> also play a major part leading on infectioncontrol issues in hospital trusts.Sources <strong>of</strong> referralThe majority <strong>of</strong> acute admissions (about 80%) comestraight from GPs or the hospital’s emergencydepartment. Others may be referred from other hospitalservices or be admitted as tertiary referrals fromoutlying DGHs. A few, such as those <strong>with</strong> HIV, mayself-refer. Some <strong>of</strong> the more vulnerable <strong>patients</strong> may bereferred by social services, the voluntary sector or fromprisons.Locality-based and/or regional servicesWhile infectious diseases units provide servicesprimarily for the hospital trust in which they are sited,most also provide a regional infection and tropicalmedicine service for more distant DGHs and GPs.Locally, the infectious diseases ward provides isolationfacilities for infectious <strong>patients</strong>, such as those <strong>with</strong> TB,and provides specialist advice for other clinicians, suchas those on intensive therapy units (ITUs). Suchfacilities and expertise can be put to use for <strong>patients</strong>transferred from other hospitals, including theprovision <strong>of</strong> negative-pressure isolation facilities orspecialist tropical diseases opinions andinvestigations.Community models <strong>of</strong> careAlthough most infectious diseases units focus on thecare <strong>of</strong> acutely ill in<strong>patients</strong>, there are increasinginteractions <strong>with</strong> community care. Many units havedeveloped programmes to provide intravenousantibiotic therapy outside hospital (outpatientantibiotic therapy (OPAT)) to enable medically stable<strong>patients</strong> to receive necessary intravenous therapy athome. In addition, HIV care involves communityliaison <strong>with</strong> social workers and community nurses toprovide holistic care. Finally, some <strong>patients</strong> <strong>with</strong>chronic fatigue syndrome (CFS) are treated bycommunity therapists. Increasingly, because <strong>of</strong> theimportance <strong>of</strong> healthcare-associated infections, thereneed to be clear links between hospitals and thecommunity to prevent and manage these infections.Infectious diseases <strong>physicians</strong> take a lead in this area,along <strong>with</strong> medical microbiologists.Complementary servicesComplementary therapies do not play a role in themanagement <strong>of</strong> infections. However, some <strong>patients</strong> <strong>with</strong>HIV can avail themselves <strong>of</strong> various complementarytherapies provided by voluntary services <strong>with</strong> links tothe infectious diseases unit.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcarePatient choice: involving <strong>patients</strong> in decisionsabout their treatmentPatients are routinely involved in decisions regardingtheir treatment. Many outpatient referrals are nowmade by ‘Choose and book’, allowing <strong>patients</strong> to see thephysician <strong>of</strong> their choice, guided by their GP. In HIVcare, patient participation in decisions about treatmentoptions is essential to maintain trust and to increase thelikelihood <strong>of</strong> adherence to <strong>of</strong>ten difficult, long-termtherapies. Before being considered for OPAT, <strong>patients</strong>are consulted as to whether or not they want toparticipate in such out-<strong>of</strong>-hospital care.Ethical and religious considerationsDue to the type <strong>of</strong> patient groups involved, great store isplaced on the religious and cultural context <strong>of</strong> patientdecision-making. In infectious diseases and tropicalmedicine, many <strong>patients</strong> come from non-UKbackgrounds and cultures. Efforts must be made toengage them in their own healthcare. Particular caremust be taken <strong>with</strong> HIV <strong>patients</strong> from other cultures,many <strong>of</strong> whom may have particular concerns abouttheir immigration status. Physicians need to be aware <strong>of</strong>the ethical aspects <strong>of</strong> decision-making in such difficultcircumstances. Similar issues may arise <strong>with</strong> <strong>patients</strong>infected <strong>with</strong> TB or hepatitis viruses.Opportunities for education and promotingself-carePatient information and education are fundamental toall aspects <strong>of</strong> medical care but are especially importantfor the vulnerable groups that are seen by infectiousdiseases <strong>physicians</strong>. Education improves patientinvolvement and helps <strong>patients</strong> to make their owndecisions about aspects <strong>of</strong> their medical care. This isclearly important in HIV disease so that individualsunderstand the need to take medication, inform theirsexual partners and practise safe sex. Similarly,education and self-help are important aspects <strong>of</strong> travelmedicine so that travellers can protect themselves fromvarious hazards associated <strong>with</strong> tropical travel.146 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Infectious diseases and tropical medicinePatients <strong>with</strong> chronic conditionsInfectious diseases practice involves <strong>working</strong> <strong>with</strong> somepatient groups <strong>with</strong> chronic conditions, even thoughmost <strong>of</strong> the activity concerns acute admissions. Those<strong>with</strong> blood-borne virus infections, notably HIV,hepatitis B and C, are frequently cared for in theoutpatient setting. There needs to be engagementbetween <strong>physicians</strong> and <strong>patients</strong>, along <strong>with</strong> other teammembers, to ensure the best long-term care andoutcomes. Difficult surgical infections, particularlyinvolving the musculoskeletal system, require long-termmanagement and close liaison <strong>with</strong> surgical colleagues.Some infectious diseases <strong>physicians</strong> also manage<strong>patients</strong> <strong>with</strong> CFS and again provide chronic care forthese individuals in a multidisciplinary team (MDT).The role <strong>of</strong> the carerCarers have an important role in managing manydiseases. The involvement <strong>of</strong> carers in the overallmanagement <strong>of</strong> those <strong>with</strong> HIV infection is <strong>of</strong>tenimportant. They can help ensure adherence to difficultdrug regimens and provide support. The same is truefor those who have to undergo difficult treatments forhepatitis C infections.Access to information, patient support groupsand the role <strong>of</strong> the expert patientInformation is provided in a variety <strong>of</strong> formsby infectious diseases units to increase patient awarenessand involvement. Patient support groups are very helpful,particularly in HIV disease where organisations suchas the Terence Higgins Trust provide invaluable supportand advice. Similarly, involvement <strong>of</strong> support groups forthose <strong>with</strong> hepatitis C or <strong>with</strong> CFS can help. The role <strong>of</strong>the expert patient is most useful in chronic conditions,such as HIV, but is more difficult for many <strong>of</strong> theacute conditions seen by infectious diseases <strong>physicians</strong>.Availability <strong>of</strong> clinical records/resultsPrompt access to records and results is an essential part<strong>of</strong> the practice <strong>of</strong> infectious diseases <strong>physicians</strong> asdecisions <strong>of</strong>ten have to be made in the acute setting.The use <strong>of</strong> information technology (IT) has improvedthe ability to access results and records. Imaging is animportant component <strong>of</strong> good infectious diseasesmanagement and this has been enhanced enormouslyby the availability <strong>of</strong> digital imaging accessibleelectronically. The electronic patient record will be amajor step to improving care. Many units now have theability to inform <strong>patients</strong> <strong>of</strong> results by email or textmessaging. This can be helpful for those <strong>with</strong> chronicconditions, such as HIV, but may also help those seekingtravel advice. Those units that provide an OPAT service(see above) usually provide <strong>patients</strong> <strong>with</strong> hand-heldrecords to facilitate their care in the community.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>Infectious diseases <strong>physicians</strong> frequently work in MDTs.The complex cases and the numbers <strong>of</strong> vulnerable<strong>patients</strong> require interactions <strong>with</strong> specialist infectiousdiseases pharmacists, specialist nurses, dietitians,occupational and physical therapists, and socialworkers. There are also close links <strong>with</strong> voluntaryorganisations, particularly those involved <strong>with</strong> HIV and<strong>with</strong> drug addiction. Infections can complicate surgicalprocedures or may require complex surgery, so MDTclinics and rounds are essential for good outcomes. Inaddition, the management <strong>of</strong> CFS requires team work<strong>with</strong> clinical psychologists.Working <strong>with</strong> other specialtiesThere are close <strong>working</strong> relationships betweeninfectious diseases <strong>physicians</strong> and clinicalmicrobiologists and virologists. There are also nowwell-established joint training programmes so thatfuture infection specialists will be accredited in bothinfectious diseases and medical microbiology. Infectiousdiseases specialists also interact closely <strong>with</strong>genitourinary medicine (GUM) specialists (particularlyin the joint management <strong>of</strong> HIV infection) <strong>with</strong>hepatologists in the management <strong>of</strong> chronic hepatitis Band C infections and <strong>with</strong> respiratory <strong>physicians</strong> inmanaging TB. Due to the acute nature <strong>of</strong> the specialty,there are many times when infectious diseases specialistswork <strong>with</strong> other <strong>physicians</strong> in the acute sector,particularly those in acute general medicine. Manyinfectious diseases <strong>physicians</strong>, acting as acute <strong>physicians</strong>themselves, play a major role in acute medicine in theirtrusts. Surgical infections are an important problem soinfectious diseases <strong>physicians</strong> interact regularly <strong>with</strong>surgeons to manage complex intraabdominal infectionsor musculoskeletal infections. There are few hospitalspecialties that do not require and seek advice frominfectious diseases <strong>physicians</strong>.Working <strong>with</strong> GPsGenerally speaking, there are no GPs <strong>working</strong> ininfectious diseases although there are many interactions<strong>with</strong> GPs needing specialist advice to manage <strong>patients</strong> inthe community. Some GPs have a special interest intravel medicine and may provide these services in theC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 147


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>NHS or the independent sector. Infectious diseases<strong>physicians</strong> are prominent in the development <strong>of</strong>antibiotic policies, not only for the hospital but alsothose that are used in primary care. They help toeducateGPsintheappropriateuse<strong>of</strong>antibioticsinthecommunity, the interpretation <strong>of</strong> laboratory tests andthe prevention and management <strong>of</strong> healthcareassociatedinfections.Specialist activity beyond local servicesInfectious diseases <strong>physicians</strong> have taken on the burden<strong>of</strong> providing clinical expertise and cover in the event <strong>of</strong>bioterrorism. Each region has an infectious diseasesphysician named as the smallpox diagnostic expert(SDE), who has been vaccinated and trained in therecognition <strong>of</strong> this disease and its management in theevent <strong>of</strong> a new case emerging. These <strong>physicians</strong> are alsoinvolved in the planning for other outbreaks, includingpandemic influenza, in conjunction <strong>with</strong> the HealthProtection Agency (HPA) and public health <strong>physicians</strong>.Infectious diseases <strong>physicians</strong> play an active role innational bodies. As well as <strong>working</strong> at the <strong>Royal</strong> <strong>College</strong><strong>of</strong> Physicians (RCP), they serve on national committeessuch as the Joint Committee on Vaccinations andImmunisations (JCVI), the Expert Advisory Group onAIDS (EAGA), the Advisory Committee onAntimicrobial Resistance and Healthcare AssociatedInfection (ARHAI) and the National Expert Panel onNew and Emerging Infections (NEPNEI). Many havehelped <strong>with</strong> the development and running <strong>of</strong> theNational Travel Health Network and Centre which nowprovides excellent advice about travel medicine to thepublic as well as to health pr<strong>of</strong>essionals.5 Delivering a high-quality serviceCharacteristics <strong>of</strong> a high-quality serviceCharacteristics <strong>of</strong> a high-quality service include: inpatient facilities and expertise 24 hours a daythroughout the year isolation rooms, including those <strong>with</strong> negativepressure ventilation same day access to out<strong>patients</strong> for acute infectionsand travellers open access to those <strong>with</strong> HIV infection open access to those <strong>with</strong> accidental blood-bornevirus exposure clinical management that takes a holistic approach regular clinical liaison <strong>with</strong> themicrobiology/virology laboratory lead on the trust’s antimicrobial policy active promotion <strong>of</strong> appropriate antimicrobial usagein the hospital lead on the trust’s infection control policies and <strong>with</strong>the team active promotion <strong>of</strong> best practice <strong>of</strong> infection control promoting safe intravenous antibiotic usage outsidethe hospital meeting recognised standards in clinical care meeting NHS targets for inpatient and outpatientwork.Maintaining and improving the quality <strong>of</strong> careLeadership role and service developmentInfectious diseases <strong>physicians</strong> <strong>of</strong>ten take leadership rolesin the hospital, in addition to having clinical leads intheir specialty. Many will serve on or chair antibioticcommittees or infection control committees in theirtrusts. They will frequently have leadership roles in theirregions for infection-related policies and links <strong>with</strong>primary care trusts (PCTs) and <strong>with</strong> the HPA.Infectious diseases <strong>physicians</strong> have taken the lead indeveloping OPAT to facilitate patient discharge, whileproviding appropriate antibiotic therapy for seriousinfections. In addition, by supporting the development<strong>of</strong> standards for managing HIV and TB, they arecontributing to improvements in the service.Education and trainingMost infectious diseases <strong>physicians</strong> are involved inteaching medical students, both preclinical and clinical.In addition, because many have academic positions,there is wider teaching, both regionally and nationally.However, some <strong>of</strong> the new medical schools do not haveinfectious diseases <strong>physicians</strong> so not all students andtrainees get exposed to such teaching, which is a gap intheir training. Most infectious diseases <strong>physicians</strong> willact as trainers for junior medical staff. Some centreshave appointed new academic clinical fellows under theWalport scheme to continue to nurture academicmedicine and, particularly, academic infectiousdiseases. The <strong>physicians</strong> also teach other trainees,including nurses and ancillary workers. Infectiousdiseases <strong>physicians</strong>, as in other specialties, have beeninvolved in training foundation doctors and inacademic training schemes. In addition, recognising theneed to encourage trainees to learn about internationalhealth, our specialty is keen to allow trainees to spendtime abroad and to encourage trainees from developingcountries to be involved in research and to get someexperience in the UK.148 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Infectious diseases and tropical medicineMentoring and appraisal <strong>of</strong> medicaland other staffAll infectious diseases <strong>physicians</strong> undergo annualappraisal through their trusts or universities, or both. Inaddition, many take on management roles and thereforethey <strong>of</strong>ten act as appraisers for their organisations. Theyalso help <strong>with</strong> assessments and appraisals <strong>of</strong> traineesand other staff.Continuing pr<strong>of</strong>essional developmentAll <strong>physicians</strong> take part in continuing pr<strong>of</strong>essionaldevelopment (CPD) activities locally, nationally andinternationally through the CPD scheme. Many, if notall, contribute by providing teaching and training forothers to contribute to their CPD. There is a minimumrequirement for consultants to achieve an average (overfive years) <strong>of</strong> 50 hours <strong>of</strong> CPD annually.Clinical governancePhysicians in infectious diseases understand the needfor good clinical governance. Through organisationssuch as the British Infection Association (BIA), theBritish HIV Association (BHIVA), the British Society <strong>of</strong>Antimicrobial Chemotherapy (BSAC), the <strong>Royal</strong> Society<strong>of</strong> Tropical Medicine and in collaboration <strong>with</strong> the<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Pathologists (RCPath), <strong>physicians</strong>develop guidelines (eg management <strong>of</strong> meningitis, feverin returning travellers and SARS) and help toimplement these locally. Through the RCP, infectiousdisease <strong>physicians</strong> have key roles on the JointCommittee on Infection and Tropical Medicine. All<strong>physicians</strong> will undergo appraisal.Research – clinical and basic scienceCompared to most medical specialties, a largeproportion <strong>of</strong> <strong>physicians</strong> in this specialty have academicappointments. At least half are academics (up to 80% <strong>of</strong>those in tropical medicine have academicappointments) and contribute significantly to researchnationally and internationally. Research varies frombasic science, <strong>of</strong>ten virological or immunological,through to clinical science and clinical trial work.British tropical medicine continues to have a highinternational pr<strong>of</strong>ile in subjects as diverse as malaria,HIV, TB, dengue fever and rickettsial diseases.Local management dutiesMost infectious diseases <strong>physicians</strong> play an active role inlocal management, either as clinical leads or serving oncommittees for infection control. Most have taken onclinical directorships and some have become medicaldirectors <strong>of</strong> trusts. Most will have managementresponsibilities relating to MDTs.Specialty and national guidelinesInfectious diseases <strong>physicians</strong> and their pr<strong>of</strong>essionalsocieties help to formulate and comment on guidelinesfrom the National Institute for Health and CareExcellence (NICE), the RCP and other organisations.Manyindividualshaveservedoncommitteest<strong>of</strong>ormulate guidelines such as those dealing <strong>with</strong>meningitis, TB and HIV. These have been published byBIS, BHIVA and other organisations.Specialty and national auditInfectious diseases <strong>physicians</strong> routinely take part innational audits organised by the HPA, BHIVA andothers, and contribute to the surveillance <strong>of</strong> infections.In addition, they are involved in the use <strong>of</strong> audit toassess clinical and other services in their own trusts.6 Clinical work <strong>of</strong> consultantsThe clinical work <strong>of</strong> infectious diseases consultantsincludes the following: Inpatient work: most infectious diseases <strong>physicians</strong>are responsible for the care <strong>of</strong> acute admissions <strong>with</strong>infection-related problems. A typical physicianwould be responsible for 500–600 admissions perannum. Outpatient work: out<strong>patients</strong> is an important facet<strong>of</strong> the physician’s work and increasingly involves thecare <strong>of</strong> those <strong>with</strong> HIV and hepatitis virusinfections. A physician would be expected to see1,000–1,200 out<strong>patients</strong> per year. Specialist procedures: infectious diseases is not aprocedure-based specialty but <strong>physicians</strong> <strong>of</strong>ten haveto deal <strong>with</strong> occupational exposure to blood-bornepathogens in healthcare workers and sort outpost-exposure prophylaxis for HIV exposures.However, an important ‘procedure’ is the need toprovide timely consultations to other services toprovide the best infection care. Consultation work isan important part <strong>of</strong> the infectious diseasesphysician’s workload. Specialist on call: most <strong>physicians</strong> will take part in aregular on-call rota for infectious diseases. Due tothe acute nature <strong>of</strong> the specialty this <strong>of</strong>ten requiresthe presence <strong>of</strong> the physician in the hospital out <strong>of</strong>hours and involves weekend ward rounds. Most<strong>physicians</strong> would expect to be part <strong>of</strong> an on-call rota<strong>of</strong> one in three or less.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 149


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> Other specialist activity: infectious diseases<strong>physicians</strong> <strong>of</strong>ten provide advice beyond the bounds<strong>of</strong> their local hospital trusts, either by telephoneadvice to DGH <strong>physicians</strong> and GPs or by providingeasy-access outpatient review for <strong>patients</strong> fromoutlying areas. Clinically related administration: all <strong>physicians</strong> needto keep on top <strong>of</strong> the administration related to theirclinical activity, including good data collection,appropriate audit and management <strong>of</strong> junior staff.Good communication <strong>with</strong> other colleagues is animportant aspect <strong>of</strong> this.Balance between acute and specialty careMost infectious diseases <strong>physicians</strong> take part in generalmedicine on-take in addition to their specialty role.This is important as the specialty is not ‘organ-based’and still requires a breadth <strong>of</strong> general medicineknowledge and experience. Many will divide their timebetween specialty and general medicine by doing somemonths <strong>of</strong> general medicine and the remainder ininfectious diseases, while maintaining their specialtyclinics throughout.Balance between direct work and supervisionMuch <strong>of</strong> the work <strong>of</strong> infectious diseases is ‘hands on’,although the clinical work does involve the delegation<strong>of</strong> some duties to junior doctors and requires theconsultant to supervise such work. Increasingly, <strong>with</strong>the reduction in junior doctors’ hours <strong>of</strong> work and theimplementation <strong>of</strong> the ‘Hospital at night’ in NHShospitals, infectious diseases consultants are <strong>of</strong>ten oncall <strong>with</strong> none <strong>of</strong> their own specialty junior staff andend up doing more direct care than in previous years.Other workAlthough infectious diseases <strong>physicians</strong> rarely, if ever,work in the community they are involved <strong>with</strong>supervising intravenous antibiotic therapy in thecommunity as part <strong>of</strong> OPAT programmes. Some willhave other duties including infection control work orthey may, <strong>with</strong> microbiology colleagues, have a role inthe supervision <strong>of</strong> diagnostic laboratories. Infectiousdiseases <strong>physicians</strong> have an active role in academicmedicine and research.7 Opportunities for integrated careMuch infectious diseases practice is, necessarily, basedin the acute hospital, whether running a ward orconsulting on <strong>patients</strong> admitted under other specialties.However, opportunities do exist for integrated care. Theprovision <strong>of</strong> OPAT is a good example <strong>of</strong> this. There willalso be increasing opportunities for the management <strong>of</strong><strong>patients</strong> <strong>with</strong> chronic blood-borne virus infections, likeHIV, and those <strong>with</strong> tuberculosis.8 Workforce requirements for the specialtyCurrent workforce numbersThere are currently around 136 whole time equivalentconsultants in infectious diseases and tropical medicine.About two-thirds are also involved in some way in acute(on-take) general medicine and a large number are inacademic positions. The infectious diseases <strong>physicians</strong>tend to be in teaching hospitals <strong>with</strong> a relative paucity inDGHs so the number <strong>of</strong> specialists is well below thatrequired for the population and is approximately halfthe number per 250,000 population compared tocountries in northern Europe. Numbers <strong>of</strong> infectiousdiseases consultants would need to expand by about40% in order to satisfy the RCP and specialist societyrecommendations for adequate provision <strong>of</strong> specialistservices (to around 190 WTE). Although fewretirements are expected in the next few years, thespecialty may expand as more trainees emerge who arejointly trained in infectious diseases and medicalmicrobiology. The expectation is that these jointtrainees will be appointed to hospitals <strong>with</strong>outinfectious diseases specialists at present and will be ableto provide clinical inpatient work as well as infectioncontrol expertise and microbiology advice.Recommendations for providing servicesThe UK has a very low number <strong>of</strong> infectious diseasesspecialists in comparison to other western countries.Currently there is only about one infectious diseasesphysician per 500,000 population in England and Wales.In Scotland, the ratio is better, <strong>with</strong> one per 270,000.Scandinavian countries <strong>with</strong> good provision have aboutone infectious diseases specialist per 50,000 population.Countries more akin to the UK, such as the Netherlandsor Australia, have one per 200,000. It is thought that thisfigure would be more appropriate for the UK – oneinfectious diseases physician for each district hospital.Medical microbiologists contribute greatly to themanagement <strong>of</strong> infection in the UK, but even if theirnumbers were included in the tally <strong>of</strong> infectious diseasesspecialists, the UK is underprovided compared to othersimilar countries. In addition, the fact that at least half<strong>of</strong> the infectious diseases <strong>physicians</strong> contribute to thegeneral medicine on-take service means that there areeven fewer WTE <strong>physicians</strong> devoted purely to infectiousdiseases.150 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Infectious diseases and tropical medicine9 <strong>Consultant</strong> work programme/specimenjob planTable 1 shows a work programme for infectious diseasesand tropical medicine <strong>physicians</strong>.Table 1 Work programme for infectious diseases andtropical medicine <strong>physicians</strong> ∗ActivityFrequencyWard rounds 2 per week 2Clinics 2 per week 2MDT meeting 1 per week 0.25X-ray meeting 1 per week 0.25Patient-related admin per week 0.5Ward consultation work ad hoc in week 2Weekend rounds 1 weekend/month 0.5Supervising trainees 2 per consultant 0.5Postgraduate meetings 2 per week 0.5Governance/revalidation 0.25Teaching weekly 0.25Research 1Clinicalsupportingprogrammedactivities∗ The table assumes an inpatient ward <strong>of</strong> 20–25 <strong>patients</strong>, and 15–20consultations <strong>with</strong> <strong>patients</strong> outside the ward. It does not include acutegeneral medicine work.10 Key points for commissioners1 Infectious diseases units provide care for <strong>patients</strong><strong>with</strong> acute infections, including imported ones andthis requires 24-hour availability, single-roomavailability and, ideally, less than 100% bedoccupancy.2 Because infectious diseases units commonly deal<strong>with</strong> contagious infections, they need to have goodisolation facilities <strong>with</strong> single rooms, includingnegative pressure ventilation for some rooms, inorder to provide safe respiratory isolation forconditions like TB.3 Infectious diseases <strong>physicians</strong> are very involved<strong>with</strong> the inpatient and outpatient management <strong>of</strong>those <strong>with</strong> blood-borne virus infections (eg HIV)and need to be able to provide outpatientmanagement for increasing numbers <strong>of</strong> cases assurvival rates are now so much better.4 Job planning for infectious diseases <strong>physicians</strong>needstotakeintoaccountthefactthatmuch<strong>of</strong>their work involves providing clinical consultationand advice for doctors in other specialties.5 Infectious diseases <strong>physicians</strong> provide a keygovernance role <strong>with</strong> their activities aroundinfection control and involvement in antibioticstewardship.6 Most infectious diseases <strong>physicians</strong> are involved inacademic work and the ability to fostertranslational research will be increasinglyimportant for the NHS.7 Infectious diseases <strong>physicians</strong> need the resourcesand flexibility to deal <strong>with</strong> outbreaks, whether <strong>with</strong>known pathogens like swine influenza or new oneslike SARS.8 Because infectious diseases units <strong>of</strong>ten deal <strong>with</strong>vulnerable groups such as refugees, intravenousdrug users, prisoners etc they need good access toancillary services.9 Many infectious diseases <strong>physicians</strong> are dualtrained in general medicine and can help toimprove the quality <strong>of</strong> infection control andmanagement on the acute medical ‘take’.10 If, as is likely, pathology services becomecentralised, those infectious diseases <strong>physicians</strong>jointly trained in microbiology will be neededto provide test interpretation and qualityassurance.Note to readers: This chapter has not been updated for the revised 5th edition 2013. The text has been reproduced from the 2011 edition.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 151


2 Specialties Medical oncologyMedical oncologyDr Johnathan J<strong>of</strong>fe MBBS MD FRCP <strong>Consultant</strong> medical oncologistDr Janine Mansi MBBS MD FRCP <strong>Consultant</strong> medical oncologistDr Dan Stark MB BChir PhD FRCP Workforce lead for SAC in Medical OncologyAlison Norton Administrator, Association <strong>of</strong> Cancer Physicians1 Description <strong>of</strong> the specialtyMedical oncologists are specialist <strong>physicians</strong> trained inthe investigation and care <strong>of</strong> <strong>patients</strong> <strong>with</strong> cancer. Theyare an integral part <strong>of</strong> the cancer multidisciplinary team(MDT), providing particular expertise to <strong>patients</strong>through their knowledge <strong>of</strong> the systemic treatment <strong>of</strong>cancer <strong>with</strong> hormonal treatment, conventionalcytotoxic chemotherapy and newer molecular-targetedtreatments. These treatments may be delivered <strong>with</strong>both curative intent, particularly in early cancers, andpalliative intent to alleviate symptoms plus,increasingly, for prolonging life in more advancedcancers. Medical oncologists are especially trained tounderstand the biology <strong>of</strong> cancer and the pharmacology<strong>of</strong> drugs. They are ideally prepared for the role <strong>of</strong>monitoring the efficacy and safety <strong>of</strong> current treatmentsandalsointhetestinganddevelopment<strong>of</strong>newmedicines. Medical oncologists have a central role in theconduct <strong>of</strong> clinical trials and are expected to enter<strong>patients</strong> into nationally approved trials. Many have aremit to design and develop new treatment strategiesthrough translational research.Medical oncologists are tumour-site specialists focusingon two or three specific types <strong>of</strong> cancer. The specialtyhas a strong academic component, <strong>with</strong> many medicaloncologists having a higher degree and a highproportion <strong>with</strong> combined academic and NationalHealth Service (NHS) appointments. Increasinglymedical oncologists require skills in management andservice delivery to understand the complex issuesinvolved in introducing new treatments, commissioninghealthcare in relation to changing models <strong>of</strong> care andmonitoring standards through peer review.In addition to this specialist role, many medicaloncologists now have a defined role in the practice <strong>of</strong>‘acute oncology’, 1 a service designed to ensureappropriate and urgent management <strong>of</strong> complications<strong>of</strong> cancer and its treatment, and also the rapidassessment and diagnosis <strong>of</strong> <strong>patients</strong> presenting <strong>with</strong>symptoms <strong>of</strong> previously undiagnosed malignancy.Medical oncologists are drivers <strong>of</strong> the current focus onprevention <strong>of</strong> cancer. It is recognised that many cancerscould be prevented by lifestyle changes. For somecancers, interventions (secondary prevention) mayafford opportunities to prevent development <strong>of</strong> thedisease.Who are the <strong>patients</strong>?One in three people in the UK will be diagnosed <strong>with</strong>cancer during their lifetime. This rate will increase asthe population grows proportionally older, which partlyexplains the increasing incidence and prevalence <strong>of</strong>cancer year on year. Advances in the early detection <strong>of</strong>cancer and major improvements in treatment haveresulted in a decrease in cancer mortality, <strong>with</strong> morepeople surviving cancer. Although many bigimprovements in survival have been in rarer cancersaffecting younger <strong>patients</strong>, new therapies for commoncancers are delivering similar advances in older people.This trend for improved survival will continue over thenext decade as still better methods <strong>of</strong> prevention,diagnosis and treatment are delivered.As well as caring for <strong>patients</strong> <strong>with</strong> active cancer, medicaloncologists are involved in monitoring and supportingcancer survivors.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceSince the government appointment <strong>of</strong> a national cancerdirector in England, cancer care in the UK has beenrevolutionised through a number <strong>of</strong> important strategicpublications, 2–4 each taking forward the development<strong>of</strong> the structure <strong>of</strong> cancer services.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 153


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Referral <strong>of</strong> <strong>patients</strong> <strong>with</strong> suspected cancer is usuallyinitiated by the patient’s GP. In England, Wales andNorthern Ireland, waiting-time targets ensure that thetime from referral to diagnosis to first definitivetreatment is as short as possible. All suspected andproven cases <strong>of</strong> cancer are discussed <strong>with</strong>in an MDT toagree an appropriate treatment. All MDTs require activeattendance and participation by cancer site-specialisedoncologists. More recently, further targets in Englandhave been set to improve the whole patient pathway,<strong>with</strong> all subsequent treatments to be given <strong>with</strong>in 31days <strong>of</strong> the decision to treat.Locality-based and/or regional servicesMDT meetings take place <strong>with</strong>in cancer units forcommon tumour types. Less common tumour types arecentralised <strong>with</strong>in a cancer centre <strong>with</strong> a critical volume<strong>of</strong> <strong>patients</strong> and staff to deliver the highest possiblestandard <strong>of</strong> care. The constitution is specific for eachtumour type as set out by improving outcomesguidance (IOG). 5 Until the reorganisation <strong>of</strong> the healthservice in April 2013, cancer units were each part <strong>of</strong> one<strong>of</strong> 34 cancer networks, <strong>with</strong> each network serving apopulation <strong>of</strong> 1–3 million. Since this date the networkfunctions are being absorbed into the new strategicclinical networks that will serve larger populations andcover multiple specialist areas. Within each networkthere are tumour site-specific boards to ensure acoordinated approach for both the organisation <strong>of</strong>services and the equity <strong>of</strong> access for <strong>patients</strong>. There is anestablished national programme <strong>of</strong> peer review toensure that services are appropriate, effective and in line<strong>with</strong> national guidance. There is increasing focus onnew models <strong>of</strong> care, eg centralising wherever necessaryto improve outcomes for complex treatment delivery.Inpatient care and acute oncologyPatients may be admitted acutely to almost anydepartment when they present <strong>with</strong> symptoms orcomplications <strong>of</strong> advanced disease or complicationsrelated to therapy. Recently the focus has moved on tothe safe and effective out-<strong>of</strong>-hours management <strong>of</strong><strong>patients</strong> receiving chemotherapy and the care <strong>of</strong>non-elective <strong>patients</strong> admitted <strong>with</strong> cancer. 1 InEngland, the National Cancer Action Team (NCAT)introduced the new multidisciplinary specialty <strong>of</strong> ‘acuteoncology’, which addresses more effective diagnosticpathways for new <strong>patients</strong> presenting acutely <strong>with</strong>symptoms <strong>of</strong> cancer, reducing unnecessaryinvestigations and length <strong>of</strong> stay. It also ensures thesafest management <strong>of</strong> complications <strong>of</strong> disease ortreatment, addressing the concerns <strong>of</strong> the NationalConfidential Enquiry into Patient Outcome and Death(NCEPOD), which investigated deaths <strong>with</strong>in 30 days <strong>of</strong>systemic anticancer therapy. 63 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareInteraction <strong>with</strong> <strong>patients</strong>Medical oncologists work <strong>with</strong> <strong>patients</strong> and theirfamilies to provide a holistic approach to care thatrecognises their right to information, autonomy,support and guidance that are sensitive to their culturalbackground and appropriate to their knowledge andbeliefs. Medical oncologists are trained in advancedcommunication skills so that they can deliver bad newsin an empathic fashion, and discuss the risks andbenefits <strong>of</strong> complex and toxic treatments or, perhaps, noactive therapy at all. This may include difficultdiscussions <strong>of</strong> statistical risk <strong>of</strong> relapse or the benefits <strong>of</strong>palliative therapies that may be associated <strong>with</strong>significant toxicity.Very <strong>of</strong>ten, where new treatments keep <strong>patients</strong> well<strong>with</strong> advanced disease over long periods, medicaloncologists provide ongoing and continuous support to<strong>patients</strong> and their families over many years. In thesesituations, the cancer can be considered as a chronicdisease requiring repeated assessment and discussionrelating to ongoing management.Involving <strong>patients</strong> in decisions about theirtreatmentMedical oncologists’ communications skills arecomplemented by involvement, if necessary, <strong>of</strong>appropriate interpreters and patient advocates. Thedecisions in oncology are <strong>of</strong>ten complex. Verbalinformation is always reinforced <strong>with</strong> written, audio orvideo material. Validated internet resources, such as thewebsites <strong>of</strong> Macmillan Cancer Support(www.macmillan.org.uk), the National CancerResearch Institute (NCRI) (www.ncri.org.uk)andCancer Research UK (www.cancerresearchuk.org), areprovided to interested <strong>patients</strong>.Medical oncologists contributed to and led many <strong>of</strong> theworkstreams <strong>of</strong> the English National ChemotherapyImplementation Group (NCIG), including those154 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Medical oncologyaround standardised ‘prescriptions’ <strong>of</strong> information andthe process and documentation <strong>of</strong> consent. The NCIGceased to exist in 2013 but medical oncologists now leadand participate in the Chemotherapy Clinical ReferenceGroup, which has taken on many <strong>of</strong> the roles <strong>of</strong> NCIG.Over the next 2 years, in collaboration <strong>with</strong> Macmillan,standardised national consent forms will be introducedto ensure higher standards <strong>of</strong> consent for systemiccancer treatment. This work, including patient nursingand pharmacy staff, has been led by medical oncology,initially through the NCIG and now through the JointCollegiate Council for Oncology (JCCO). Medicaloncologists are key members and <strong>of</strong>ten leaders <strong>of</strong> MDTsin which the patient is at the centre <strong>of</strong> any managementdecision. Adherence to national guidelines, the IOG, 5ensures high-quality services. All <strong>patients</strong> should be<strong>of</strong>fered participation in appropriate clinical trials, whichmay facilitate access to drugs that are not otherwiseprovided by the NHS. Medical oncologists arerepresented(<strong>of</strong>tenaschairpeople)onallrelevantNCRIclinical studies groups on which patient representativesensure that <strong>patients</strong>’ voices are heard as early as possibleduring the planning stages <strong>of</strong> clinical trials.Increasing importance is paid to provision <strong>of</strong>psychological support and to access to informationabout financial support. With more <strong>patients</strong> survivingthrough cure or prolonged control <strong>of</strong> cancer, survival isbecoming an important issue for many. Medicaloncologists are increasingly involved in identifying,monitoring and treating late effects, both <strong>of</strong> cancer and<strong>of</strong> its treatment.Patient support groupsLocal self-help groups <strong>with</strong>in hospitals and thecommunity can improve patient education andsupport. Medical oncologists provide staff education<strong>with</strong>in the specialist oncology team, the general hospitaland the community services that provide much <strong>of</strong> thepatient care. The expert <strong>patients</strong>’ programme provideslay-led, group-based support for <strong>patients</strong>, empoweringthem to improve their quality <strong>of</strong> life despite living <strong>with</strong>a long-term condition. The National Awareness andEarly Diagnosis Initiative (NAEDI) is coordinating aprogramme <strong>of</strong> activity to raise public awareness <strong>of</strong> signsand symptoms <strong>of</strong> early cancer to encourage people toseek help sooner.Patients may wish to explore complementary therapytogether <strong>with</strong> standard treatment. This need has beenrecognised in a paper published by the JCCO. 74 Interspecialty and interdisciplinary liaisonand opportunities for integrated careMedical oncology is by design, and by national guidance,an integrated specialty through MDT <strong>working</strong>.Multidisciplinary team <strong>working</strong>All newly diagnosed <strong>patients</strong> are discussed in a relevantMDT meeting and a recommended treatment plan isagreed in accordance <strong>with</strong> tumour site-specificguidelines and protocols. Often medical oncologists arethe coordinators <strong>of</strong> these treatment plans, <strong>working</strong> <strong>with</strong>other specialties to create defined care pathways bothfor elective care and <strong>with</strong>in acute oncology.Working <strong>with</strong> other specialtiesWithin the MDT, medical oncologists work closely <strong>with</strong>surgeons, <strong>physicians</strong>, clinical oncologists, radiologists,pathologists, specialist nurses and the palliativecare team. The MDTs are required to communicateeffectively <strong>with</strong> those in primary care who, in turn, havetargets to ensure prompt referral <strong>of</strong> new <strong>patients</strong>. 2,3An RCP/RCR <strong>working</strong> party has recently published adocument, Cancer <strong>patients</strong> in crisis – responding to urgentneeds, which was produced by specialists in medicaloncology, clinical oncology, palliative care, emergencymedicine, intensive care, acute medicine, together <strong>with</strong>patient representatives in recognition <strong>of</strong> the complexities<strong>of</strong> acute cancer management in emergency situations. 8Working <strong>with</strong> GPs and GPs <strong>with</strong> a special interest(GPwSIs)Communication <strong>with</strong> GPs is vital to provide seamlesscare at all stages <strong>of</strong> a patient’s illness. Patients in remissionrequire a coordinated follow-up strategy. Palliativetreatments require excellent communication andcoordination between oncologists and the community.Medical oncologists are frequently the non-surgicaloncology leads for trusts, providing input into themanagement and planning <strong>of</strong> services and <strong>working</strong>closely <strong>with</strong> trust management and primary care trusts(PCTs) on commissioning issues.Other specialty activity beyond local servicesMost medical oncologists will be based in a cancercentre and provide a number <strong>of</strong> direct clinical care(DCC)-programmed activities (PAs) in a peripheralcancer unit <strong>with</strong>in their network. For some, theprincipal site <strong>of</strong> activity is <strong>with</strong>in a cancer unit and theywill visit their cancer centre for audit, research andcontinuing pr<strong>of</strong>essional development (CPD).C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 155


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>With the introduction <strong>of</strong> acute oncology, every trustthat cares for elective and non-elective admissions <strong>with</strong>cancer must establish an MDT that ensures that thereare pathways for the care <strong>of</strong> <strong>patients</strong> presenting for thefirst time <strong>with</strong> cancer, or at later stages <strong>with</strong>in theircancer journey <strong>with</strong> complications due to disease ortreatment. Addressing this neglected area <strong>of</strong> cancer carerepresents new activity for medical oncologists where akey requirement is availability at an early stage. Thisrequires investment through strong partnerships <strong>of</strong>commissioners, cancer service providers and cancernetworks. New medical oncology posts are beingestablished to support this additional workload,recognised as sessions <strong>of</strong> DCC <strong>with</strong>in job plans.Joint Collegiate Council for OncologyOn a national level medical oncologists work <strong>with</strong>colleagues from clinical oncology and haematologythrough the JCCO to provide a nationally coordinatedforum for guidance and advice to government andcommissioners. The JCCO includes patient/userrepresentation and has participation from theDepartment <strong>of</strong> Health through the membership <strong>of</strong> thenational cancer director.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality service can be judged by the criteria <strong>of</strong>patient satisfaction, adherence to national and networkguidelines and accreditation standards, and theachievement <strong>of</strong> outcomes which, when audited andcompared <strong>with</strong> national cancer care standards andpublished reports, are deemed to be excellent.The NCIG (directed through the NCAT) developed keyperformance indicators that provide benchmarks forthe assessment <strong>of</strong> the quality <strong>of</strong> oncology services.Cancer is increasingly a long-term condition and manycancer survivors receive complex and toxic ongoingdisease-modifying treatments. It is imperative thatreductions in new:follow-up ratios are not used as aquality indicator in this setting.Maintaining and improving the standard <strong>of</strong> careThe system <strong>of</strong> cancer peer review ensures adherence toguidelines such as the IOG and cancer strategypublications. 1–5 Medical oncologists lead and supportthese processes and are key members on other nationalbodies, such as the National Institute for Health andCare Excellence (NICE) and NCIG, tasked <strong>with</strong>improving standards and outcome.Service developments to deliver improvedpatient careMedical oncologists are at the centre <strong>of</strong> nationalplanning <strong>of</strong> cancer services, research and therapiesthrough the Association <strong>of</strong> Cancer Physicians (ACP),NICE, the <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP), the JCCO,Cancer Research UK, the Department <strong>of</strong> Health (DH)and, previously, the <strong>of</strong>fice <strong>of</strong> the national cancerdirector.Systemic anti-cancer therapy dataset (SACT)In the last 3 years NCIG, through a <strong>working</strong> party led bymedical and clinical oncologists, established a nationalchemotherapy database (which is now coordinatedthrough the National Cancer Information Network). Atpresent all chemotherapy activity in England, wherethere is electronic prescribing <strong>of</strong> chemotherapy, is beingcharacterised <strong>with</strong>in a standard dataset (SACT) and sentmonthly to the database. Within the next year, allchemotherapy activity will be required to be uploadedto the database. These data will provide aninternationally unique resource that will be used foraudit, and benchmarking <strong>of</strong> both activity andmeaningful outcomes such as survival.Education and trainingMedical oncology is a thriving specialty. The lastworkforce census reported an annual increase <strong>of</strong>consultants by 6.3% (compared <strong>with</strong> 5.3% for medicalspecialties as a whole). 9The training and supervision <strong>of</strong> specialty registrars(StRs) is becoming more detailed and time-consuming.There are currently 248 trainees <strong>with</strong>in 25 trainingprogrammes across the UK. The minimum time forhigher specialist training in oncology is 4 years, but, as itis a research-based specialty, many undertake extraout-<strong>of</strong>-programme research.A competency-based curriculum has been developedwhich incorporates the 17 Postgraduate MedicalEducation and Training Board (PMETB) standards.Formal assessment <strong>of</strong> competence in procedures,knowledge, understanding <strong>of</strong> clinical trials, clinicalskills and attitudes <strong>of</strong> the aspiring medical oncologistfall to the existing consultant body through the use <strong>of</strong>assessment tools, including mini-clinical examination(mini-CEX) and multisource feedback appraisal. SinceNovember 2010, trainees sit the specialty examination156 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Medical oncologyset by the ACP and the medical oncology specialistadvisory committee (SAC).The academic nature <strong>of</strong> medical oncology is recognised<strong>with</strong>in the curriculum and the award <strong>of</strong> a Certificate <strong>of</strong>Completion <strong>of</strong> Training (CCT) recognises time spent inresearch. In addition, the National Institute for HealthResearch (NIHR) has established a number <strong>of</strong>academically based training opportunities in which 30current trainees have basic and translational researchembedded in their training programme.Clinical governanceWith its tradition <strong>of</strong> audit and research, medicaloncology is strongly oriented towards maintainingclinical standards and effectiveness. The rigours <strong>of</strong>research governance through good clinical practice(GCP), 10,11 which defines standards for the conduct <strong>of</strong>clinical research, prepare medical oncologists fordelivery <strong>of</strong> high standards in routine practice. Medicaloncologists lead and support audits which are anessential part <strong>of</strong> the peer-review process; these includethe NICE assessment and implementation <strong>of</strong> new drugs.Research – clinical studies and basic science Medical oncology is a research-based specialty.Therapy is in a constant state <strong>of</strong> evolution,depending on the latest, validated, clinical research.Medical oncologists must be competent andcommitted clinical scientists, whether <strong>working</strong> inacademiccentresorcancerunits. Ithasbeendemonstratedthat<strong>patients</strong>treated<strong>with</strong>in a clinical trial fare better. The NationalCancer Research Network (NCRN) has set a target<strong>of</strong> 10% <strong>of</strong> cancer <strong>patients</strong> to be entered intorandomised clinical trials. All medical oncologistsare expected to support this activity. Many will haveundertaken laboratory research during training(obtaining a PhD or MD) and can develop andsupport translational, pharmacological and basicclinical research.Local, regional and national dutiesMedical oncologists are increasingly involved in rolessuch as: leadership <strong>of</strong> tumour group at trust or network level leadership and involvement in drug and therapeuticcommittees leadership <strong>of</strong> acute oncology teams leadership in guideline development clinical service lead/medical director roles regional specialty advisers education programme leadership/trainingprogramme directors educational and clinical supervisors for trainees leads for tumour-specific research groups – local,network and national regional and national committees – RCP, ACP, JCCOand national <strong>working</strong> parties.Specialty and national guidelinesMost medical oncologists contribute to continuingdevelopment <strong>of</strong> comprehensive guidelines for themanagement <strong>of</strong> different cancers through regionalprotocols and national guidelines, <strong>of</strong>ten through NICE,IOG, 5 specialist societies, JCCO and NCRN.Medical oncologists have also led work for the ‘Map <strong>of</strong>Medicine’ and national information pathways tosupport <strong>patients</strong> at key points during their cancerjourney, through partnership <strong>with</strong> Cancer Research UK(www.cancerresearch.org) and Macmillan CancerSupport (www.macmillan.org.uk).Quality tools and frameworksAs indicated in other sections, through development <strong>of</strong>robust databases and prescribing systems andcontribution to the development <strong>of</strong> guidelines that arefollowed nationally, medical oncologists are at theforefront <strong>of</strong> creating benchmarks for clinicallymeaningful outcomes through audit, peer review andother quality assessment tools.6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialtyThe medical oncologist is the leader and coordinator <strong>of</strong>an extended team <strong>of</strong> pr<strong>of</strong>essionals through regularMDT meetings, and will attend one or more each weekdepending on the volume <strong>of</strong> work and sitespecialisation. This should be a maximum <strong>of</strong> threetumour sites because <strong>of</strong> the increasing range andcomplexity <strong>of</strong> treatments and patient numbers.Most cancer <strong>patients</strong> receive their care in the out<strong>patients</strong>etting and day-care wards. Patients may be admitted fordiagnosis, treatment and management <strong>of</strong> complications.All medical oncologists manage <strong>patients</strong> <strong>with</strong> multiplecomorbidities and treat critically ill <strong>patients</strong> <strong>with</strong>oncological emergencies. Medical oncologists supportacute medicine through provision <strong>of</strong> the acute oncologyservice.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 157


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Sample job plan for consultant medical oncologistActivity Workload Programmed activities (PAs)Direct clinical careOutpatient clinicDay-care ward work3–4 new patient consultations per week: approximately 1 houreach. Routine follow-up <strong>of</strong> well <strong>patients</strong>: 10–15 minutes’consultation. Management <strong>of</strong> <strong>patients</strong> <strong>with</strong> relapsed or metastaticdisease: approximately 30 minutesMay form part <strong>of</strong> a mixed outpatient clinic. Patient assessmentand chemotherapy prescribing: approximately 30 minutes2–41–2Acute oncology 1 or more PAs may be appropriate in some job plans


2 Specialties Medical oncologyTable 2 Sample job plan for academic medical oncologist <strong>with</strong> a major laboratory interestActivityProgrammed activities (PAs)Direct clinical careInpatient care (ward rounds and ward consultations) 1.0MDTs/MDT meetings 0.75Outpatient clinics 1.5Patient administration and clinical follow-up (letters, referrals, telephone calls) 1.75On call (supporting junior doctor on-call arrangements) 0.5Total number <strong>of</strong> direct clinical care PAs 5.5Supporting pr<strong>of</strong>essional activities (SPAs)Medical education 0.25CPD 0.25Research (clinical trials, translational research in drug development, supervision <strong>of</strong> MD and PhDstudents)Other NHS duties (local trust committees, eg research and development, clinical governance andaudit)3.250.25External duties (international boards, lectures on behalf <strong>of</strong> employing institution) 0.5Total number <strong>of</strong> supporting pr<strong>of</strong>essional activities 4.5Total programmed activities 10Note: medical oncologists, particularly in academic centres, may work <strong>with</strong> other consultant medical oncologists as part <strong>of</strong> a team sharing theoutpatient and inpatient care <strong>of</strong> a group <strong>of</strong> <strong>patients</strong>. In this case, responsibilities may vary weekly or monthly, for which an annualised job planis required.CPD = continuing pr<strong>of</strong>essional development; MDT = multidisciplinary meeting.7 Workforce requirements for the specialtyThe number <strong>of</strong> medical oncologists has risen from 138in November 2000 to 408 in September 2012. WithMDT <strong>working</strong>, an ageing population, additional lines <strong>of</strong>treatment available, ongoing drug development andsubsequent personalisation <strong>of</strong> cancer treatment, as wellas the generation <strong>of</strong> acute oncology services, thenumber <strong>of</strong> medical oncologists required has inevitablyincreased. To adequately provide an acute oncologyservice, approximately 100 new posts will be requiredacross the UK. The provision <strong>of</strong> acute oncology isrecognised <strong>with</strong> new posts as follows: 9 <strong>of</strong> a total <strong>of</strong> 36new appointments in 2009–10, 12 <strong>of</strong> 26 posts in2010–11 and 20 <strong>of</strong> 39 posts in 2011–12, <strong>with</strong> potentiallya further 100 posts for the provision <strong>of</strong> personalisedmedicine. Therefore, the predicted workforcerequirement in the UK is a minimum <strong>of</strong> 550 posts,representing 2.75 whole-time equivalent (WTE) postsper 200,000–250,000 population.8 <strong>Consultant</strong> work programme/specimenjob planThe workload <strong>of</strong> a medical oncologist, measured by thenumber <strong>of</strong> new <strong>patients</strong> seen annually, should beapproximately 200 (100–150 for academic medicaloncologists). Due to the lack <strong>of</strong> specialist oncologists inmuch <strong>of</strong> the UK, the workload <strong>of</strong> the majority <strong>of</strong>medical oncologists exceeds this.An on-call rota <strong>of</strong> oncology specialists should provide24-hour emergency cover, if necessary together <strong>with</strong> colleaguesfrom haematology or clinical oncology to ensuresufficient numbers for a rota (maximum one in five).9 Key points for commissioners1 Medical oncology is a specialty that should berepresented in every cancer centre and most cancerMDTs.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 159


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>2 The requirement for systemic cancer therapy isincreasing through new therapies, the ageingpopulation, personalised complex therapies andprolonged survival <strong>with</strong> cancer.3 Patients surviving cancer require increasingspecialist intervention and monitoring to maintainremission and to deal <strong>with</strong> late effects <strong>of</strong> cancer andtherapies.4 Acute oncology is a new multidisciplinary service<strong>of</strong>fering significant gains in quality <strong>of</strong> patient careand clinical efficiency.5 Acute oncology requires an invest-to-save approachby commissioners and providers.6 Clinical trials are a prerequisite <strong>of</strong> high-qualitycancer care and are an expected component <strong>of</strong>medical oncologists’ direct clinical care.7 Translational research supports new treatmentsand subsequently better outcomes for <strong>patients</strong> <strong>with</strong>cancer. Medical oncologists are key drivers <strong>of</strong> theconcept <strong>of</strong> bench to bedside.8 Medical oncologists lead the development andintegration <strong>of</strong> new treatments safely into routinepractice.9 Training and education in systemic therapy forjunior medical staff and other healthcarepr<strong>of</strong>essionals are a vital part <strong>of</strong> the role <strong>of</strong> themedical oncologist.10 The SACT dataset and database will provide aunique resource for benchmarking and audit <strong>of</strong>chemotherapy activity and outcomes. New qualityindicators will need to be developed to supportcommissioning and management <strong>of</strong> advanceddisease, which in many areas is becoming along-term condition. Particular attention isrequired in relation to supervision <strong>of</strong> new andadditional therapeutic options, as well as survivalissues, complications and patient self-managementinitiatives.References1 Department <strong>of</strong> Health. Chemotherapy services in England:ensuring quality and safety. A report by the NationalChemotherapy Advisory Group. London: DH, 2009.http://ncat.nhs.uk/sites/default/files/NCAG%20Report.pdf2 Department <strong>of</strong> Health. The NHS cancer plan: a planfor investment, a plan for reform. London: DH,2000.3 Department <strong>of</strong> Health. Cancer reform strategy. London:DH, 2007. www.cancerscreening.nhs.uk/breastscreen/dh-081007.pdf4 Department <strong>of</strong> Health. Improving outcomes: a strategy forcancer. London: DH, 2011. www.gov.uk/government/uploads/system/uploads/attachment data/file/135516/dh 123394.pdf.pdf5 National Institute for Health and Care Excellence.Improving outcomes guidance. London: NICE. www.nice.org.uk/Search.do?x=12&y=15&searchText=Improving+outcomes+guidance&newsearch=true#/search/?reload[Accessed 21 March 2013].6 National Confidential Enquiry into Patient Outcome andDeath. For better, for worse? A review <strong>of</strong> the care <strong>of</strong> <strong>patients</strong>who died <strong>with</strong>in 30 days <strong>of</strong> receiving systemic anticancertherapy. London: NCEPOD, November 2008. www.ncepod.org.uk/2008report3/Downloads/SACT report.pdf7 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Radiologists. Interactions between cancertreatment and herbal and nutritional supplements andmedicines: information for doctors. BFCO (06)3. London:RCR, 2006. www.rcr.ac.uk/index.asp?PageID=149&PublicationID=239 [Accessed 21 March 2013].8 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians and <strong>Royal</strong> <strong>College</strong> <strong>of</strong>Radiologists. Cancer <strong>patients</strong> in crisis: responding to urgentneeds. Report <strong>of</strong> a <strong>working</strong> party. London: RCP, 2012.www.rcplondon.ac.uk/sites/default/files/documents/cancer-<strong>patients</strong>-in-crisis-report.pdf [Accessed 21 March2013].9 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK.Census <strong>of</strong> consultant <strong>physicians</strong> and medical registrars inthe UK, 2011: data and commentary. London: RCP, 2013.www.rcplondon.ac.uk/sites/default/files/census <strong>of</strong>consultant <strong>physicians</strong> and medical registrars in the uk2011 1.pdf [Accessed 21 March 2013].10 Medical Research Council. Guidelines for good clinicalpractice in clinical trials. London: MRC, 1998.www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC002416 [Accessed 21 March 2013].11 Directive 2001/20/EC <strong>of</strong> the European Parliament and <strong>of</strong>the council <strong>of</strong> 4 April 2001. Official Journal <strong>of</strong> theEuropean Communities 2001;L121;34–44. http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2001:121:0034:0044:en:PDF [Accessed 21 March 2013].160 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Medical ophthalmologyMedical ophthalmologyDr Richard P Gale BSc MBChB MRCP MRCOphth MEd<strong>Consultant</strong> medical ophthalmologistDr Catherine Guly MbChB MRCOphth MRCP(UK)<strong>Consultant</strong> medical ophthalmologist1 Description <strong>of</strong> the specialty‘Ophthalmic <strong>physicians</strong>’ or ‘medical ophthalmologists’are trained in both medicine and ophthalmology andare skilled in the diagnosis and management <strong>of</strong> systemicdiseases affecting the eyes and vision as well asophthalmic conditions that do not require surgery.Patients <strong>with</strong> generalised vascular, autoimmune,neoplastic, inherited and degenerative disorders mayfirst present <strong>with</strong> ophthalmic symptoms and signs andan understanding <strong>of</strong> systemic disease, as well as thecomplex interaction between physical, social andpsychological factors, is essential to providing a holisticapproach to patient care. 1Medical ophthalmologists have varying roles around theUK but are mainly employed as ophthalmic specialistscaring for <strong>patients</strong> and providing services in one ormore <strong>of</strong> the following areas: ocular inflammation (which includes uveitis andinflammatory diseases <strong>of</strong> the cornea and orbit) diabetic eye disease neuro-ophthalmic problems (vision and the brain) retinal disease (which includes age-related maculardegeneration (AMD), retinal vascular occlusionsand hereditary eye diseases).Ophthalmic <strong>physicians</strong> may undertake laser treatments<strong>of</strong> the retina and deliver drug injections into the eye(intravitreal injections). Other roles undertaken bysome ophthalmic <strong>physicians</strong> include supervision <strong>of</strong> eyecasualty or primary care clinics and managing diabetesretinal screening programmes. Ophthalmic <strong>physicians</strong>support <strong>patients</strong> <strong>with</strong> visual impairment, and theirfamilies, and provide access to rehabilitation and socialsupport services.With an ageing population, an increasing prevalence <strong>of</strong>diabetes and the growing use <strong>of</strong> biological therapies(intravitreal and systemic), the workload and demandfor ophthalmic <strong>physicians</strong> is expected to continue toincrease.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralOrganisation <strong>of</strong> the serviceOphthalmic <strong>physicians</strong> are usually based inophthalmology departments or eye hospitals but havelinks <strong>with</strong> other <strong>physicians</strong>. Most <strong>patients</strong> are seen<strong>with</strong>in the ophthalmic setting but some ophthalmic<strong>physicians</strong> <strong>of</strong>fer outreach services to neurology andinfectious disease units and for hospital in<strong>patients</strong>.Services are usually outpatient based, <strong>with</strong> access today-case and inpatient beds required for a minority <strong>of</strong><strong>patients</strong>.ReferralsOphthalmic <strong>physicians</strong> receive referrals from otherophthalmologists, GPs, <strong>physicians</strong> and optometrists,and through the diabetes retinal screening programme.Direct referral from community optometrists isencouraged for certain conditions where a delayedreferral could result in loss <strong>of</strong> vision, for example in thecase <strong>of</strong> AMD. Many conditions managed by ophthalmic<strong>physicians</strong> initially present urgently through eyecasualty clinics.Ophthalmic <strong>physicians</strong> generally <strong>of</strong>fer secondary andtertiary level care although some <strong>of</strong>fer primary carethrough supervision <strong>of</strong> eye casualty or primary careclinics. Tertiary referrals usually involve <strong>patients</strong> <strong>with</strong>complex ocular inflammatory or neuro-ophthalmicdiseases.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareEnsuring that the patient is at the centre <strong>of</strong> thingsPatient education and support is fundamental to thepractice <strong>of</strong> medical ophthalmology, where many<strong>patients</strong> have chronic disease and lifestyle factors caninfluence the visual and systemic outcomes. TheDepartment <strong>of</strong> Health’s Supporting people <strong>with</strong>long-term conditions 2 discusses the importance <strong>of</strong> givingC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 161


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong><strong>patients</strong> the knowledge and skills to care for themselves.For example, good blood-glucose and blood-pressurecontrol reduce the risk <strong>of</strong> progression <strong>of</strong> diabeticretinopathy and help to preserve vision. Liaison <strong>with</strong>GPs, <strong>physicians</strong> and specialist nurses is important toreinforce these messages and to provide additionalsupport. Skilful counselling is required to inform andeducate while recognising the individual’s expertise intheir own condition.Patient support groups, which include those for <strong>patients</strong><strong>with</strong> visual loss and those <strong>with</strong> specific medicalconditions, enable <strong>patients</strong> to gain from the lifeexperience and understanding <strong>of</strong> others. An ophthalmicphysician will have links <strong>with</strong> one or more localsocieties for the visually impaired and many alsosupport charities at a national level.Visual impairmentOphthalmic <strong>physicians</strong> need to take account <strong>of</strong> thespecial needs <strong>of</strong> the patient <strong>with</strong> visual impairment,whether temporary or long term. The <strong>Royal</strong> NationalInstitute <strong>of</strong> Blind People (RNIB) ‘Losing PatientsCampaign’ has highlighted the difficulties faced byblind and partially sighted people who are given healthinformation that they cannot read. 3 Patient informationshould be available in a format that is accessible to<strong>patients</strong> <strong>with</strong> visual impairment and currently the NHSfalls behind on this ideal. Staff should be trained toassist those <strong>with</strong> visual impairment and to be alert tothe difficulties <strong>of</strong> communicating for <strong>patients</strong> <strong>with</strong> dualsensory impairment.In the UK, only one in three blind or partially sightedpeople is <strong>working</strong>. 4 Diabetic retinopathy and uveitis arethe leading causes <strong>of</strong> visual impairment in the <strong>working</strong>years <strong>of</strong> life 5 and these groups in particular need accessto specialist employment advice, which is usuallyprovided through charities. Advancing technology andcomputer s<strong>of</strong>tware mean that many <strong>patients</strong> <strong>with</strong> sightloss can <strong>of</strong>ten retain their jobs if they are given adequatesupport.Timely registration using the certificate <strong>of</strong> visualimpairment (form BP1 in Scotland) enables <strong>patients</strong><strong>with</strong> poor vision to gain access to practical and financialsupport (although access to services for the visuallyimpaired should always be on the basis <strong>of</strong> need ratherthan registration).Ethical and religious considerationsOphthalmic <strong>physicians</strong> should be sensitive to culturaland religious beliefs and how these impact on a patient’sacceptance and understanding <strong>of</strong> their condition andtreatment.Patient-centred eye servicesA patient seeing an ophthalmic physician may need tohave a number <strong>of</strong> assessments and investigations, eg anorthoptic assessment and a visual field test for aneuro-ophthalmic appointment or retinal photographyand optical coherence tomography imaging at a diabeteseye clinic. Treatments such as intravitreal injections andretinal laser therapy are provided through outpatientdepartments.Services should be organised to enable <strong>patients</strong> to havetheir investigations and clinical review at the sameappointment wherever possible to minimise hospitalattendances. The <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Ophthalmologistsissued guidelines on the commissioning <strong>of</strong> services forAMD in 2007 and recommends a ‘one-stop’ clinic,where investigations and treatments are performed atthe same visit. 64 Interspecialty and interdisciplinary liaisonWithin the ophthalmology department, ophthalmic<strong>physicians</strong> work closely <strong>with</strong> ophthalmic surgeons,optometrists, orthoptists, ophthalmic photographers,electrophysiologists and ophthalmic nurses.Increasingly, ophthalmic nurses and optometrists arebeing trained to see and manage <strong>patients</strong> according toprotocols for conditions such as AMD and acuteanterior uveitis.Working <strong>with</strong> ophthalmologistsOphthalmology is divided into a number <strong>of</strong> subspecialtyareas and while the vast majority <strong>of</strong> <strong>patients</strong> aremanaged by one specialist, some <strong>patients</strong> may bemanaged by an ophthalmic physician in association<strong>with</strong> an ophthalmic surgeon. Patients may need to bereferred on for ophthalmic surgery, and others <strong>with</strong>complex disease benefit from seeing an ophthalmologist<strong>with</strong> a special interest in their condition, eg a patient<strong>with</strong> glaucoma secondary to uveitis may see anophthalmic physician, for control <strong>of</strong> their ocularinflammation, as well as a glaucoma specialist.An ophthalmic physician may be called to assist <strong>with</strong>the management <strong>of</strong> ophthalmic <strong>patients</strong> <strong>with</strong> medicalneeds, for example a patient under the care <strong>of</strong> a cornealsurgeon requiring immunosuppression for a complexcorneal transplant.162 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Medical ophthalmologyWorking <strong>with</strong> other specialtiesOphthalmic <strong>physicians</strong> work closely <strong>with</strong> otherspecialties, although the specialties vary depending onthe areas covered. The following list is not exhaustivebut shows the variety <strong>of</strong> specialties that interact <strong>with</strong>medical ophthalmology: ocular and orbital inflammation – rheumatology,renal medicine, respiratory medicine,endocrinology, dermatology, infectious diseases,microbiology, haematology and radiology neuro-ophthalmology – neurology, neurosurgery,endocrinology, stroke, rehabilitation medicine andradiology diabetic eye disease – diabetes, renal medicine andobstetrics medical retina – clinical genetics and stroke.Working <strong>with</strong> community servicesThe traditional organisational boundaries <strong>of</strong> primaryand secondary care are becoming blurred 7 and this isparticularly true for ophthalmic practice <strong>with</strong> thegrowing role <strong>of</strong> community-based optometry services.Chronic disease management (eg diabetes) andprevention <strong>of</strong> disease (eg smoking cessation) arecommonly organised through general practice.Increasingly, optometrists are taking on extended rolesand being trained to diagnose and manage specificanterior segment eye conditions and glaucoma.Effective communication between different communityservices and between hospital and community servicesis vital to ensure that <strong>patients</strong> are referred in a timelyand appropriate fashion.Ophthalmology departments work <strong>with</strong> local socialwork departments and societies for the visuallyimpaired to ensure that <strong>patients</strong> <strong>with</strong> sight loss are ableto live as independently as possible. Eye clinic liaison<strong>of</strong>ficers exist in some centres to provide information,emotional support and advice to <strong>patients</strong> and cruciallyact as a link between the eye clinic, rehabilitationservices (such as low vision aid assessments) andsupport services in the community for <strong>patients</strong> <strong>with</strong>visual impairment.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality medical ophthalmology service is onethat bridges the gap between hospital ophthalmicservices, medical care and community-based care, usingresources efficiently and effectively to provide acoordinated, patient-centred service for those <strong>with</strong>medical ophthalmic problems.Effective communication <strong>with</strong> <strong>patients</strong> and theirfamilies and between ophthalmic <strong>physicians</strong> and otherhealth pr<strong>of</strong>essionals involved, including those incommunity services, is essential.Quality <strong>of</strong> services should be monitored andophthalmic <strong>physicians</strong> should audit the performance <strong>of</strong>their services regularly, eg recording complication ratesfrom intravitreal injections and visual outcomes fortreated AMD.Ophthalmic <strong>physicians</strong> have a responsibility to train notonly doctors and trainee doctors but also members <strong>of</strong>the wider team, which may include nurses, optometristsand orthoptists. They have a leadership role <strong>with</strong>in thehospital eye service and may choose to take on othermanagement responsibilities or roles <strong>with</strong>in theNational Health Service (NHS), deanery, university orcollege.Ophthalmic <strong>physicians</strong> should manage their owncontinuing pr<strong>of</strong>essional development (CPD) and have aresponsibility to maintain their knowledge and skills, topractise safety and to keep up to date <strong>with</strong> newdevelopments. They should recognise their limitationsand work <strong>with</strong>in their capabilities, referring <strong>patients</strong> onor seeking advice where appropriate.Societies and collegesThe Medical Ophthamological Society UK is thepr<strong>of</strong>essional society for ophthalmic <strong>physicians</strong>(www.mosuk.co.uk). The <strong>Royal</strong> <strong>College</strong> <strong>of</strong>Ophthalmologists (www.rcophth.ac.uk)isthepr<strong>of</strong>essional body for ophthalmologists, which includesophthalmic <strong>physicians</strong>, and has a role in trainingdelivery, manpower planning and other pr<strong>of</strong>essionalissues. The Joint <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians TrainingBoard (JRCPTB) runs the medical ophthalmologytraining programme, 8 <strong>with</strong> input from the <strong>Royal</strong><strong>College</strong> <strong>of</strong> Ophthalmologists. Trainees in medicalophthalmology enter specialty training (ST) at ST3 levelfrom either core medical training or ophthalmologytraining.GuidelinesThe following guidelines are relevant to medicalophthalmology:C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 163


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Diabetic eye disease <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Ophthalmologists. Diabeticretinopathy preferred practice screening guidance. 9 NHS Quality Improvement, Scotland. Diabeticretinopathy screening clinical standards. 10 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Ophthalmologists. Guidelines fordiabetic retinopathy. 9Age-related macular degeneration <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Ophthalmologists. Maximisingcapacity in AMD services. 9 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Ophthalmologists. Guidelines formanagement <strong>of</strong> AMD. 9 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Ophthalmologists. Guidelines forintravitreal injections procedure. 9Retinal vein occlusion <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Ophthalmologists. Interimguidelines for the management <strong>of</strong> retinal veinocclusion. 96 Clinical work <strong>of</strong> consultantsMedical ophthalmology is an outpatient-based specialtyalthough there are usually facilities for day-case andinpatient admission for a minority <strong>of</strong> <strong>patients</strong>.Most ophthalmic <strong>physicians</strong> do not participate inout-<strong>of</strong>-hours work, but it would be feasible foran ophthalmic physician to be on an ophthalmologyon-call rota if there was cover provided by anophthalmic surgeon for the small proportion <strong>of</strong> casesthat require urgent surgery.Specialist clinics such as ocular inflammation andneuro-ophthalmology require direct consultantinvolvement and close supervision <strong>of</strong> trainees. With thehigh-demand services like AMD and diabeticretinopathy, there is <strong>of</strong>ten a more supervisory role.Ophthalmic <strong>physicians</strong> need to facilitate rapid referraland diagnosis <strong>of</strong> <strong>patients</strong> <strong>with</strong> macular degenerationand are responsible for the quality <strong>of</strong> the service. Otherhealth pr<strong>of</strong>essionals such as nurses and optometristsmay be trained to assess and manage <strong>patients</strong> <strong>with</strong>macular degeneration according to protocols. ‘Virtualclinics’, where clinical decisions are made on the basis <strong>of</strong>ocular images and visual acuity, are used in somecentres for diabetic maculopathy to determine which<strong>patients</strong> need to be seen in the diabetes eye clinic.Clinical administration work can be time consumingdue to the large numbers <strong>of</strong> referrals and outpatientreviews. Ocular inflammation and neuroophthalmologyclinics are particularly demanding asadditional investigations are <strong>of</strong>ten required and apatient may be under the care <strong>of</strong> a number <strong>of</strong> specialists.7 Opportunities for integrated careMedical ophthalmology is complex. Hospital services,general practice, community eye services and socialservices need to be coordinated. Optometrists servelocal communities and have the ability to perform amore complete ophthalmic examination than can beachieved in general practice but until recently this hasbeen underused by the NHS. The role <strong>of</strong> theoptometrist has been reviewed in the Generalophthalmic services review (2007) 11 and the Review <strong>of</strong>community eyecare services in Scotland (2006). 12Optometrists are now taking on extended roles, in someareas taking referrals from general practice, managinganterior segment eye conditions and glaucoma in thecommunity <strong>with</strong> extended prescribing rights, and<strong>working</strong> up more complex cases to a higher level beforethey are referred to the hospital eye service. 12 Linkingcommunity optometrists <strong>with</strong> social services andhospital eye services allows optometrists to identifythose <strong>with</strong> failing sight and to refer on for treatmentand social-work assessments where appropriate.Cost-effective evidence-based treatments are lacking ina number <strong>of</strong> areas <strong>of</strong> medical ophthalmology butparticularly in the field <strong>of</strong> ocular inflammation wherethere are no licensed immunosuppressive medications.Clinical research should be encouraged and integrated<strong>with</strong> routine clinical care.8 Workforce requirements for the specialtyThere are currently 10 consultant medicalophthalmologists and eight trainees in the UK. Thereare no academic medical ophthalmologists or academictraining posts at present.More than half <strong>of</strong> new referrals to ophthalmology arefor medical rather than surgical ophthalmic problems. 13It is recognised that there is a lack <strong>of</strong> trained medicalspecialists and that a substantial expansion in numbers<strong>of</strong> consultants is required to deliver services in the UK.It is estimated that a ratio <strong>of</strong> one ophthalmic physicianto eight ophthalmic surgeons in a unit is required, and itis predicted that in the future there will be one164 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Medical ophthalmologyTable 1 Typical job plan <strong>of</strong> a medical ophthalmologistActivitySessionsDirect patient care 7.5Outpatient clinics – which may include: ocular inflammation clinic, neuro-ophthalmology clinic, diabetic eye diseaseclinic, medical retina clinic, AMD clinicProcedures (injection or laser)Retinal screeningAdministrationInpatient (ward rounds, referrals, MDT meetings)This may include: inpatient and day-case workNeuroradiology meetingElectrophysiology meetingOcular imaging meeting(NB: for units <strong>with</strong> a large tertiary referral cohort, there may be additional inpatient or day-case work and fewerclinics.)Supporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong> healthcare 2.5ophthalmic physician per 263,000 population. 14 Thenumber <strong>of</strong> ophthalmic <strong>physicians</strong> needs to be balanced<strong>with</strong> the workforce plans for ophthalmology and thecurrent plan is to expand the workforce to around100 consultant ophthalmic <strong>physicians</strong> to providespecialist medical services to ophthalmic <strong>patients</strong>.The JRCPTB is <strong>working</strong> <strong>with</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong>Ophthalmologists to support the specialty to expandthe number <strong>of</strong> medical ophthalmology trainingprogrammes to 16 and to provide opportunities foracademic training.9 <strong>Consultant</strong> work programme/specimenjob planThe range <strong>of</strong> activities a medical ophthalmologist wouldconduct in a typical week is reflected in Table 1. Like allspecialties, the workload can be heavy at times, <strong>with</strong>some busy clinics, but the <strong>working</strong> times are usuallyquite predictable.10 Key points for commissioners1 Medical ophthalmology is a diverse specialty andthe needs <strong>of</strong> an individual service will depend onthe specialist interest <strong>of</strong> the ophthalmic physicianand the requirements <strong>of</strong> the local population.2 Ophthalmic <strong>physicians</strong> provide secondary andtertiary level care to <strong>patients</strong> <strong>with</strong> complexproblems, including those <strong>with</strong> ocularinflammation, neuro-ophthalmic disease, diabeticeye disease, inherited eye diseases and degenerativeconditions.3 Specialist clinics for ocular inflammation andneuro-ophthalmology require direct consultantinvolvement. With the high-demand services likeAMD and diabetic retinopathy, there is <strong>of</strong>ten amore supervisory role.4 Procedures performed by ophthalmic <strong>physicians</strong>include retinal laser and intravitreal injections.5 Recent pharmacological developments and anageing population mean that the workload for anophthalmic physician has increased substantiallyand is likely to continue to increase.6 Medical ophthalmology is predominantlyoutpatient based but day-case and inpatientfacilities are required for a minority <strong>of</strong><strong>patients</strong>.7 All ophthalmic <strong>physicians</strong> require a comprehensiveocular imaging service and access to optometrists.Those <strong>working</strong> in neuro-ophthalmology requireC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 165


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>orthoptic support, electrophysiology andneuroimaging services.8 Ophthalmic <strong>physicians</strong> need to be able to interact<strong>with</strong> the wider team in order to act as an effectivelink between medical and ophthalmic care. Thismay involve joint ward rounds and clinics,multidisciplinary radiology meetings and ocularimaging meetings.9 Education <strong>of</strong> doctors in training, trainee doctorsand other members <strong>of</strong> the team, includingoptometrists and nurses, is an important part <strong>of</strong>the role <strong>of</strong> the consultant ophthalmic physician.10 Integrating research into clinical care is a priorityfor medical ophthalmology as the evidence base islacking, particularly in the management <strong>of</strong> ocularinflammation and neuro-ophthalmic conditions.References1 Dick AD, Forrester JV. The ophthalmic physician: anindulgence or a necessity? Br J Ophthalmol1996;80:782–3.2 Department <strong>of</strong> Health. Supporting people <strong>with</strong> long-termconditions. London: DH, 2005. www.dh.gov.uk/prod consum dh/groups/dh digitalassets/@dh/@en/documents/digitalasset/dh 4122574.pdf [Accessed 15December 2010]3 <strong>Royal</strong> National Institute <strong>of</strong> Blind People. Losing <strong>patients</strong>.Why are blind and partially sighted <strong>patients</strong> still givenhealth information in print they cannot read? Campaignsreport 28. www.rnib.org.uk [Accessed 15 December2010]4 <strong>Royal</strong> National Institute <strong>of</strong> Blind People. Employmentcampaign briefing autumn 2009. www.rnib.org.uk[Accessed 15 December 2010]5 Rothova A, Suttorp-Schulten MS. The possible impact <strong>of</strong>uveitis in blindness: a literature survey. Br J Ophthalmol1996;80:844-8.6 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Ophthalmologists. Commissioningcontemporary AMD services: a guide for commissionersand clinicians. Version 3. London: RCOphth, July 2007.www.rcophth.ac.uk. [Accessed 15 December 2010]7 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians and <strong>Royal</strong> <strong>College</strong> <strong>of</strong> GeneralPractitioners. Making the best use <strong>of</strong> doctor’s skills– a balanced partnership. London: RCP, RCGP, April 2006.http://old.rcplondon.ac.uk/news/statements/jointRCPGP.pdf [Accessed 21 June 2011]8 Joint <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians Training Board.Medical ophthalmology specialty training curriculum2010. www.jrcptb.org.uk/specialties/ST3-SpR/Pages/Medical-Ophthalmology.aspx [Accessed 15 December2010]9 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Ophthalmologists. Clinical guidelines.www.rcophth.ac.uk/page.asp?section=451&sectionTitle=Clinical+Guidelines [Accessed 15 December 2010]10 NHS Quality Improvement Scotland. Diabeticretinopathy screening. Clinical standards – March 2004.www.ndrs.scot.nhs.uk/Links/Docs/drstandards2004.pdf[Accessed 15 December 2010]11 Department <strong>of</strong> Health. General ophthalmic servicesreview. London: DH, January 2007. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 063984 [Accessed 15 December2010]12 Scottish Executive. Review <strong>of</strong> community eyecare servicesin Scotland: final report. Edinburgh: Scottish Executive,December 2006. www.scotland.gov.uk/Publications/2006/12/13102441/0 [Accessed 15December 2010]13 Greiner K, McCormack K, Grant A, Forrester JV. Therelative contribution <strong>of</strong> medical and surgical referrals tothe workload in general ophthalmic practice. Br JOphthalmol 2003;87:933–5.14 Centre for Workforce Intelligence. Medical specialtyworkforce factsheet: medical ophthalmology. CFWI: August2010. www.cfwi.org.uk [Accessed 15 December 2010]Note to readers: This chapter has been reproduced from the book’s 5th edition (2011) as the author felt it did not need updating for the 2013 revision.166 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Metabolic medicineMetabolic medicineDr Ruth M Ayling <strong>Consultant</strong> chemical pathologist1 Description <strong>of</strong> the specialtyMetabolic medicine (MM) can be defined as a group<strong>of</strong> overlapping areas <strong>of</strong> clinical practice <strong>with</strong> commondependence on detailed understanding <strong>of</strong> basicbiochemistry and metabolism. Those areas are: disorders <strong>of</strong> nutrition,eg obesity, <strong>patients</strong> requiring parenteral nutrition inherited metabolic disease (IMD),eg phenylketonuria, galactosaemia, urea cycledefects, glycogen storage disorders abnormalities <strong>of</strong> lipid metabolism andcardiovascular risk assessment disorders <strong>of</strong> calcium metabolism and bone,eg osteoporosis, vitamin D deficiency, Paget’sdisease, osteogenesis imperfecta, renal stones diabetes mellitus.They fall <strong>with</strong>in the expertise <strong>of</strong> both the physician andbiochemist. With regard to training, MM is considereda subspecialty and whilst it is possible to specialise <strong>with</strong>a background in general internal medicine, most MM<strong>physicians</strong> are also trained in chemical pathology.The <strong>patients</strong> cared for by MM <strong>physicians</strong> are a diversegroup across all age ranges. Many have chronicdisorders that require long-term follow-up. Advances indiagnostics such as developments in neonatal screeningand new treatments such as enzyme replacementtherapies are bringing novel management challenges,particularly for <strong>patients</strong> <strong>with</strong> IMD.In each domain the MM physician works to lead andcoordinate the activities <strong>of</strong> a multidisciplinary teamconfirming a biochemical diagnosis, institutingtreatment, preventing complications and <strong>of</strong>feringinformation, help and support.MM <strong>physicians</strong> who are chemical pathologists alsoprovide pr<strong>of</strong>essional direction in a clinical biochemistrylaboratory. In addition to providing interpretativeadvice on a wide range <strong>of</strong> clinical biochemistry tests forGPs and hospital colleagues, they are particularly wellplaced to advise on any aspects that fall <strong>with</strong>in the fivemetabolic medicine domains listed above.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralMM is a new and developing specialty so it is notpossible to describe a typical service. Although MM<strong>physicians</strong> are trained in all five domains, most willsubspecialise in two according to the needs <strong>of</strong> theservice in which they work. In a district general hospitaland some teaching hospitals, MM <strong>physicians</strong> mighthave clinical responsibilities such as the management <strong>of</strong><strong>patients</strong> receiving parenteral nutrition and those <strong>with</strong>abnormalities <strong>of</strong> lipid metabolism and cardiovascularrisk assessment or disorders <strong>of</strong> calcium metabolism andbone, in addition to duties <strong>with</strong>in the clinicalbiochemistry laboratory. The clinical biochemistrylaboratory service is led by an MM physician trained inchemical pathology and comprises a mixture <strong>of</strong> clinicaland scientific staff. The MM consultant hasresponsibility for hospital outpatient clinics as well asproviding ward referrals and care <strong>of</strong> <strong>patients</strong> admittedfor investigation.In other settings such as a tertiary referral centre, theMM physician may specialise in just one domain,eg IMD, to deliver a more clinically focused service,particularly in adults. As many metabolic disorders arecomparatively rare, laboratory and clinical networksexist and are being further developed to link regionalservices to district general hospitals and so ensure awide delivery <strong>of</strong> full diagnostic services and tertiarylevel clinical care.The majority <strong>of</strong> referrals to MM <strong>physicians</strong> are fromGPs or consultant colleagues. As the specialty becomesbetter established it is anticipated that referrals willincrease, for example adult <strong>patients</strong> <strong>with</strong> IMD nothaving the opportunity to be cared for by a physician<strong>with</strong> specific expertise and <strong>patients</strong> <strong>with</strong> metabolic bonedisease not currently being seen in a dedicatedmultidisciplinary clinic, are two obvious groups.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 167


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareOptimal management <strong>of</strong> metabolic disease involvesinforming <strong>patients</strong> and engaging them in theirtreatment. Many metabolic disorders require complexnutritional modifications, and dietetic regimens need tobe tailored to the requirements, lifestyle and preferences<strong>of</strong> individual <strong>patients</strong> for success.Patient-centred carePatient choice: cultural considerationsIt is essential that the MM specialist appreciates andresponds to the needs <strong>of</strong> people from different culturalbackgrounds. Innovative approaches have been tried insome regions, particularly <strong>with</strong> respect to diabetes andlipid management, and the nature <strong>of</strong> the specialty favoursrapid dissemination <strong>of</strong> examples <strong>of</strong> good practice.Patient support groupsPatient support groups are available in all domains <strong>of</strong> thespecialty and play a vital role in providing information,peer support and counselling. Examples include: disorders <strong>of</strong> nutrition – Patients on Intravenous andNasogastric Nutrition Therapy (PINNT) (www.pinnt.com) abnormalities <strong>of</strong> lipids – Heart UK (www.heartuk.org.uk) disorders <strong>of</strong> calcium metabolism and bonemetabolism – National Osteoporosis Society(www.nos.org.uk) IMD – Contact a Family (www.cafamily.org.uk),National Society for Phenylketonuria (NSPKU)(www.nspku.org) diabetes–DiabetesUK(www.diabetes.org.uk).Many MM <strong>physicians</strong> are involved <strong>with</strong> the <strong>patients</strong>upport groups relevant to their own domain(s) <strong>of</strong>interest <strong>with</strong>in the specialty at local or national level.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>MM favours a multidisciplinary team (MDT) approach.The members <strong>of</strong> the team and their particular expertisewill vary according to the domain involved. Forexample, an MM physician prescribing parenteralnutrition will work closely <strong>with</strong> an appropriately skilledspecialist nurse, dietitian and pharmacist. Aphysiotherapist is an essential team member in aspecialist outpatient clinic where <strong>patients</strong> <strong>with</strong> bonedisease are seen.Working <strong>with</strong> other specialtiesMM has key links <strong>with</strong> a number <strong>of</strong> other specialties, eg: gastroenterology, general surgery cardiology orthopaedics, rheumatology paediatrics obstetrics endocrinology.This illustrates the breadth <strong>of</strong> skills that the MMphysician needs in order to maximise the expertise <strong>of</strong>other medical and surgical colleagues to best advantage.Working <strong>with</strong> GPs and GPs <strong>with</strong> a special interestSome metabolic disorders such as commondyslipidaemias and diabetes mellitus are frequentlyencountered in general practice and it is essential forMM <strong>physicians</strong> to work closely <strong>with</strong> GPs to ensureappropriate care pathways and optimal care, particularlyfor those <strong>patients</strong> who have chronic metabolic disorders.5 Delivering a high-quality serviceMaintaining and improving the quality <strong>of</strong> careA high-quality MM service will be well staffed, wellresourced and consultant led. It will be supported by anaccredited clinical biochemistry laboratory <strong>of</strong>fering afull repertoire <strong>of</strong> investigations to enable the diagnosisand monitoring <strong>of</strong> metabolic disease.Service developments to deliver improvedpatient careMM <strong>physicians</strong> maintain and improve quality <strong>of</strong>care both for their <strong>patients</strong> and in clinical biochemistrylaboratories for which they have responsibility.This is achieved by involvement in management,clinical governance, pr<strong>of</strong>essional self-regulation,continuing pr<strong>of</strong>essional development (CPD), educationand training and by the provision <strong>of</strong> specialist adviceat local, regional and national levels. They participatein laboratory quality control and national externalquality assurance schemes and projects that auditoutcomes. The MM physician is also responsible for theimplementation <strong>of</strong> guidelines from bodies such as the<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Pathologists, the National Institute forHealth and Care Excellence (NICE) and the Department168 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Metabolic medicine<strong>of</strong> Health (DH), which define the facilities, servicesand treatment that should be available for <strong>patients</strong>.Education and trainingEducation and training are important aspects <strong>of</strong> the work<strong>of</strong> MM <strong>physicians</strong> who teach and train medical students,qualified doctors in many disciplines, nurses and laboratoryscientists. The training curriculum for MM 1 reflectsthe need to support the development and maintenance<strong>of</strong> skills and acquisition <strong>of</strong> knowledge required for pr<strong>of</strong>iciencyin the investigation, diagnosis and management <strong>of</strong>all five MM domains, together <strong>with</strong> generic competenciesnecessary to support good medical practice.Mentoring and appraisal <strong>of</strong> medical staff andother pr<strong>of</strong>essional staffAll MM <strong>physicians</strong> undergo annual appraisal. Those<strong>with</strong> a management role will <strong>of</strong>ten act as appraisers intheir organisation. <strong>Consultant</strong>s will also assist <strong>with</strong> theappraisal and assessment <strong>of</strong> medical trainees.Continuing pr<strong>of</strong>essional developmentA minimum five-year requirement <strong>of</strong> 250 CPD credits isrequired, calculated on a five-year rolling cycle, where onecredit usually equates to one hour <strong>of</strong> educational activity.Clinical governanceA MM physician has a defined role in clinicalgovernance arrangements having responsibility for thequality <strong>of</strong> the results issued by the clinical biochemistrylaboratory. Mechanisms include participation ininternal quality control and external quality assuranceschemes and attainment <strong>of</strong> recognised accreditation.Research – clinical studies and basic scienceMM <strong>physicians</strong> are encouraged to undertakehigh-quality clinical studies and basic science researcheither individually or in collaboration <strong>with</strong> academicand scientific colleagues.Local management dutiesMM consultants can be clinical directors or hold otherleadership or management roles <strong>with</strong>in a NHS trust.Specialty and national guidelinesThere are guidelines pertinent to laboratory and clinicalaspects <strong>of</strong> all the MM domains. Some <strong>of</strong> these are fromspecialty societies, eg Disorders <strong>of</strong> nutrition guidelines for themanagement <strong>of</strong> patient <strong>with</strong> a short bowel, availablefrom the Small Bowel and Nutrition Committee <strong>of</strong>the British Society <strong>of</strong> Gastroenterology. 2 A consensus document for the diagnosis andmanagement <strong>of</strong> <strong>patients</strong> <strong>with</strong> IMD, available fromthe NSPKU. 3Guidelines from NICE include those for nutritionsupport, obesity, diabetes, cardiovascular riskassessment and lipid management and familialhypercholesterolaemia. 4Specialty and national auditAudit is carried out <strong>with</strong>in the domains <strong>of</strong> MM viaspecialist societies such as the Association for ClinicalBiochemistry (www.acb.org.uk). Relevant nationalaudits include the National Clinical Audit <strong>of</strong> theManagement <strong>of</strong> Familial Hypercholesterolaemia, 5 andthe National Diabetes Audit 6 which is considered to bethe largest clinical audit in the world.Quality tools and frameworksFor the laboratory aspects <strong>of</strong> the service, accreditation 7and benchmarking exercises, such as the nationalpathology benchmarking service, 8 provide measurablequality standards. For the clinical aspects <strong>of</strong> MM,national service frameworks have been developed fordiabetes and coronary heart disease. 96 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialtyThere is considerable variation between consultants.Those <strong>with</strong> laboratory duties may spend the equivalent<strong>of</strong> a day a week as duty biochemist <strong>with</strong> front-lineresponsibility for clinical validation <strong>of</strong> results andtroubleshooting <strong>of</strong> analytical problems and additionaltime on the development <strong>of</strong> laboratory services. Thosetrained in general internal medicine are likely to haveadditional clinical duties on the wards and mayundertake general medical outpatient clinics.Inpatient workThere is variation in the amount and type <strong>of</strong> inpatientwork according to the domains <strong>of</strong> specialist interest <strong>of</strong>MM <strong>physicians</strong>. Typical duties might include: nutrition ward round for 15 <strong>patients</strong>, 2–3 hours general medical, IMD or nutrition MDT meeting todiscuss complex <strong>patients</strong>, 1–2 hours IMD ward round for those admitted forinvestigation and more complex <strong>patients</strong> admitted<strong>with</strong> acute metabolic problems, 2–3 hoursC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 169


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> referral work: responding to requests for advice bypatient review, 1–2 hours general medical ward round and associated dutiesfor 30 <strong>patients</strong>, 4 hours.Outpatient workThere are likely to be two or three outpatient clinics perweek. In each <strong>of</strong> these, between two and six new <strong>patients</strong>and four and eight follow-up <strong>patients</strong> would beappropriate.Specialist on call<strong>Consultant</strong>s in chemical pathology may take partin an on-call rota, providing out <strong>of</strong> hourssupport on laboratory and clinically related issues bytelephone. Those <strong>with</strong> duties in general internalmedicine may well be expected to take part in a medicalon-call rota requiring attendance at the hospitalout-<strong>of</strong>-hours.7 Opportunities for integrated careIntegrated care has been defined as a concept bringingtogether inputs, delivery, management and organisation<strong>of</strong> services relating to diagnosis, treatment, care,rehabilitation and health promotion. 10 MM <strong>physicians</strong>engage <strong>with</strong> <strong>patients</strong> to identify their needs and are aware<strong>of</strong> services available, <strong>working</strong> <strong>with</strong> other pr<strong>of</strong>essionalgroups to provide them. This is particularly relevant<strong>with</strong> respect to diabetes, lipid disorders and IMD.8 Workforce requirements for the specialtyAs MM has only recently become availableas a specific training option, workforce issues are notyet clearly delineated and it has been recommended thatpr<strong>of</strong>essional bodies assess the likely future demand forMM consultants. 11 There are currently 20 consultantsin chemical pathology and MM and one consultant ingeneral internal medicine and MM, <strong>with</strong> 52 specialty registrarsin training. Increasingly new or replacement postsin chemical pathology are including a MM component.9 <strong>Consultant</strong> work programme/specimenjob planThere is potential for considerable variation in thework programmes/job plans <strong>of</strong> consultants inTable 1 Example job plan for a MM physicianActivity Work Programmed activities (PAs)Direct clinical careOutpatient clinicsInpatient ward rounds2–4 new <strong>patients</strong>4–8 follow-up <strong>patients</strong>eg nutrition10–20 <strong>patients</strong>1 per clinic0.5MDT meeting Variable 0.25–1Chemical pathology:Laboratory workClinical administrationInternal medicine:Ward workClinical administration3–40.53–41Total number <strong>of</strong> direct clinical care PAs 7.5Supporting pr<strong>of</strong>essional activitiesDuties maintaining and improving thequality <strong>of</strong> healthcareeg CPD, audit, clinical governance, teachingand training, research2.5Additional NHS responsibilities eg management by individual agreement <strong>with</strong> the trustExternal dutieseg roles <strong>with</strong>in specialist societies, royalcolleges, deaneriesby individual agreement <strong>with</strong> the trust170 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Metabolic medicinemetabolic medicine according to their domains <strong>of</strong>specialisation and whether they work in chemicalpathology or general internal medicine. Table 1 showsan example <strong>of</strong> the types <strong>of</strong> activities that might beincluded in the job plan <strong>of</strong> a MM physician <strong>with</strong> thenumber <strong>of</strong> programmed activities (PAs) relevant toeach.10 Key points for commissioners1 Metabolic medicine (MM) encompasses fivedomains:• abnormalities <strong>of</strong> lipid metabolism andcardiovascular risk assessment• disorders <strong>of</strong> calcium metabolism and bone(eg osteoporosis)• diabetes• nutrition• IMD, particularly in adults.2 Most metabolic medicine specialists are also trainedas chemical pathologists and have an important rolein providing clinical and pr<strong>of</strong>essional leadership<strong>with</strong>in the clinical biochemistry laboratory.3 Ensuring appropriate management <strong>of</strong> dyslipidaemiais essential to lowering cardiovascular morbidity andmortality and the MM physician has particularexpertiseinthisarea.4 MM <strong>physicians</strong> are trained to provide care for<strong>patients</strong> <strong>with</strong> metabolic bone disease includingosteoporosis, an increasing problem as thepopulation ages.5 MM <strong>physicians</strong> have the appropriate skills andknowledge to provide outpatient and communitycare for <strong>patients</strong> <strong>with</strong> diabetes mellitus.6 Nutritional care is <strong>of</strong>ten ignored. MM <strong>physicians</strong>can assist in improving the quality <strong>of</strong> care deliveredin this area.7 Obesity is a major public health problem andMM <strong>physicians</strong> are able to advise on its managementin the community and to deliver a specialistservice.8 Due to improvements in diagnosis and treatment,children <strong>with</strong> IMD are now surviving to adulthood.MM <strong>physicians</strong> are specifically trained to providecare for this group <strong>of</strong> <strong>patients</strong>.References1 Training curriculum for the sub-specialty <strong>of</strong> metabolicmedicine, August 2010. www.jrcptb.org.uk/specialties/ST3-SpR/Documents/2010%20Metabolic%20Medicine%20Curriculum.pdf2 Nightingale J, Woodward JH. Guidelines for management<strong>of</strong> <strong>patients</strong> <strong>with</strong> a short bowel. Gut 2006;55(Suppl 4):iv1–12.3 National Society for Phenylketonuria. Management <strong>of</strong>phenylketonuria. London: NSPKU, February 2004. www.nspku.org/Documents/Management%20<strong>of</strong>%20PKU.pdf4 National Institute for Health and Care Excellence.www.nice.org.uk5 Young KV, Humphries SE, Grant R. National clinicalaudit <strong>of</strong> the management <strong>of</strong> familial hypercholesterolaemia2009: pilot – full report. London: Clinical Effectivenessand Evaluation Unit, RCP, June 2009.6 Healthcare Quality Improvement Partnership. Nationaldiabetes audit. www.ic.nhs.uk/nda7 Burnett D.A practical guide to accreditation in laboratorymedicine. London: ACB Venture Publications, 2002.8 National Pathology Benchmarking Service. www.keele.ac.uk/pharmacy/general/npbs9 Department <strong>of</strong> Health. National service frameworks.www.dh.gov.uk10 Kodner DL, Kyriacou CK. Fully integrated care for frailelderly: two American models. Int J Integr Care 2000;1:e08.11 The Association for Clinical Biochemistry and the <strong>Royal</strong><strong>College</strong> <strong>of</strong> Pathologists. <strong>Consultant</strong>s in clinicalbiochemistry: the future. London: ACB, RCPath, 2009.www.rcpath.org/resources/pdf/g088consultantsinclinbiomay09.pdfNote to readers: This chapter has not been updated for the revised 5th edition 2013. The text has been reproduced from the 2011 edition.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 171


2 Specialties NeurologyNeurologyDr J Gareth Llewelyn BSc(Hons) MD FRCP <strong>Consultant</strong> neurologist1 Description <strong>of</strong> the specialtyNeurology is the branch <strong>of</strong> medicine dealing <strong>with</strong>disorders <strong>of</strong> the nervous system, including the brain,spinal cord, peripheral nerves and muscle. Specialistcare is provided by consultant neurologists <strong>working</strong><strong>with</strong>in a network <strong>of</strong> specialist nurses,neurophysiotherapists, occupational therapists, speechand language therapists, neuropsychologists,psychotherapists, neuropsychiatrists,neurophysiologists, <strong>physicians</strong> and surgeons, includingGPs <strong>with</strong> a special interest (GPwSIs) in conditions suchas epilepsy, Parkinson’s disease or headache.The patient <strong>with</strong> a neurological illness should easily beable to access a neurology network that includes servicesat a district general hospital (DGH), neurology centre(NC) and a regional neurosciences centre (RNC).Neurologists provide a clinical lead for teams <strong>with</strong>in thenetwork, coordinating the patient’s clinical pathway andpromoting the cause <strong>of</strong> <strong>patients</strong>.Who are the <strong>patients</strong>?Sixteen common diseases (including epilepsy, headacheand migraine) account for 75% <strong>of</strong> all new outpatientreferrals, the investigation and management <strong>of</strong> whichhave become more complex in the light <strong>of</strong> new medicaland surgical treatments. The remaining 25% <strong>of</strong> <strong>patients</strong>have unusual disorders or complex symptomatologythat requires expert assessment, sophisticatedinvestigation and management (eg spinocerebellardegeneration). All <strong>patients</strong> need prompt and carefulassessment <strong>with</strong> an appropriate and safe managementplan.Disease patternsOne in six people has a neurological condition thatmakes a significant impact on their lives. 1Every year 0.6–1% <strong>of</strong> the population is diagnosed <strong>with</strong> aneurological condition and 2% <strong>of</strong> the UK population isdisabled by a neurological illness.Long-term neurological conditions (LTNCs) are verycommon – taken together there are about a 1,000<strong>patients</strong> <strong>with</strong> epilepsy, multiple sclerosis (MS) andParkinson’s disease per 100,000 <strong>of</strong> the population.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralThe components <strong>of</strong> the network – community settingssuch as small DGHs, NCs based in larger DGHs andRNCs – should share common protocols andguidelines. Some specialist services will be based only inparts <strong>of</strong> the network or even in some parts <strong>of</strong> the UK.Community clinicsWhere appropriate, some outpatient clinic activity willbe in community settings providing a service close tothe patient’s home.District general hospital neurology centresNeurologists increasingly work together in a neurologycentre based at a DGH. They provide a general andspecial interest neurological service <strong>with</strong> clinicalneurophysiology, neuroradiology andneurorehabilitation services but <strong>with</strong>out inpatientneurosurgery facilities. These centres may haveinpatient beds for the care <strong>of</strong> acute emergencies and theinvestigation <strong>of</strong> <strong>patients</strong> <strong>with</strong> complex neurologicaldisease. The <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP) and theAssociation <strong>of</strong> British Neurologists (ABN) recommendthe development <strong>of</strong> these DGH neurology centres acrossthe UK. 2Regional neurosciences centresThese are crucial to the provision <strong>of</strong> high-quality care.They provide access to all relevant modern investigativeequipment and an appropriate environment for themanagement <strong>of</strong> both the more common disorders andtherarercomplexconditionsthat<strong>of</strong>tenrequireinputfrom more than one pr<strong>of</strong>essional. All neurologistsshould have links and be attached to a neurosciencescentre.Acute neurological services (unscheduled care)Close to 20% <strong>of</strong> acute medical admissions (includingstroke) results from neurological problems. SomeC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 173


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>are life threatening and require early specialistintervention.At the moment early access to neurological specialistadvice is not available in many DGHs in the UK. 2There needs to be an increase in neurology sessions inlarger DGHs to provide timely access to specialistopinion for <strong>patients</strong> admitted <strong>with</strong> neurologicaldisorders, <strong>with</strong> appropriate local access to relevantneurological investigations, eg neuroradiology andneurophysiology at the DGH.Patients <strong>with</strong> neurological disorders need to bemanaged on one ward <strong>of</strong> the hospital <strong>with</strong> suitablytrained nursing staff. Therapists and neurologicalrehabilitation can then be linked to this specialist team.Stroke servicesAcross the UK, neurologists have steadily but variablyincreased their involvement in acute stroke care,<strong>working</strong> in collaboration <strong>with</strong> care <strong>of</strong> elderly people,and stroke and acute internal medicine <strong>physicians</strong>, butthis needs to become more uniform, fully supportingand training junior staff.Neurology outpatient services (scheduled care)Patients <strong>with</strong> neurological problems should, wherefeasible, be seen for consultation as close to their homeas possible. Many <strong>patients</strong> <strong>with</strong> LTNCs can bemonitored by specialist nurses and/or GPwSIs, providedthat they are supported by the consultant neurologist.The principles <strong>of</strong> community care are as follows: local access for all <strong>patients</strong> <strong>with</strong> chronic neurologicaldisorders patient-centred care <strong>patients</strong> seen by an appropriately skilled clinician (egphysiotherapist, specialist nurse or consultantneurologist) identifying a key worker (nurse specialist,consultant, etc) designated consultant neurologist in charge better integration <strong>with</strong> social services improving clinical skills locally.Care pathways are required for <strong>patients</strong> <strong>with</strong> LTNCs andthe responsibilities <strong>of</strong> team members must be identified.Neurological care in the community is fully endorsed bythe RCP and ABN. 2Complementary servicesNeurologists support the use <strong>of</strong> complementarytherapies for their <strong>patients</strong> where there is an evidencebase.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong>Involving <strong>patients</strong> in decisions about theirtreatmentFollowing the initial outpatient consultation andinvestigation a diagnosis can usually be made andtreatment plans discussed <strong>with</strong> the patient, the familyand the GP. Some will require ongoing care, involvingrehabilitation and other local community services.Patients should have the name and contact details <strong>of</strong> akey worker and be able to access the most appropriatepart <strong>of</strong> the network at all times. For certain patientgroups, education, support and counselling are alsoundertaken by specialist nurses.In England, the national service framework (NSF) forlong-term conditions was launched in 2005, providing11 quality requirements to improve the care <strong>of</strong> <strong>patients</strong><strong>with</strong> LTNCs. In response, the ABN produced its owndocument setting out generic and specific guidance forimplementation <strong>with</strong> appropriate performancestandards. 3In 2011 the National Audit Office report 7 highlightedbasic problems <strong>with</strong> the NSF at its half-way stage.Services for people <strong>with</strong> long-term neurologicalconditions are not as good as they ought to be, despite alarge increase in spending. Progress in implementingthe Department’s strategy has been poor and localorganisations lack incentives to improve the quality <strong>of</strong>services.It is not clear how lessons will be learnt and there areriskstoserviceswhichtheDepartmentmustaddresstoensure that care improves.This was followed last year by a critical Public AccountsCommittee report 8 which concluded that:. . . services for people <strong>with</strong> neurological conditions aresimply not up to scratch, and the implementation <strong>of</strong> theFramework for improving neurology services has not174 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Neurologyworked . . . we identified an absence <strong>of</strong> leadership atboth national and local level and poor integration <strong>of</strong>services as key weaknesses that must be addressed. It istherefore extremely disappointing that the Departmenthas rejected our recommendations in relation to theseissues . . . the Department has got to do better and wewill be taking this up <strong>with</strong> them in due course.Neurologists are <strong>of</strong>ten part <strong>of</strong> the team providing carefor <strong>patients</strong> who are at the end <strong>of</strong> their lives. Patients,carers and families need to be kept fully informed aboutprognosis and the range <strong>of</strong> services available. It isessential to coordinate pain control and emotional andpsychological care.Patient support groupsPatients and carers should have access to high-qualityinformation about their neurological condition,investigations and treatment, and to local branches <strong>of</strong>neurological charities, together <strong>with</strong> a wide range <strong>of</strong>healthcare workers. Increasingly, neurological <strong>patients</strong>are experts in their condition and may be part <strong>of</strong> themultidisciplinary team (MDT) as expert <strong>patients</strong>.Availability <strong>of</strong> clinical records and resultsAll <strong>patients</strong> should be <strong>of</strong>fered copies <strong>of</strong> clinic letters andthe results <strong>of</strong> investigations. Patient records should beavailable at all times to all treating agencies. This is nowincreasingly possible by electronic means.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>Neurologists frequently work as part <strong>of</strong> MDTs whencaring for acutely ill <strong>patients</strong> and especially for <strong>patients</strong><strong>with</strong> LTNCs. Clinical nurse specialists and therapists<strong>with</strong> knowledge <strong>of</strong> neurological conditions are key teammembers and some should be based in the community.Links <strong>with</strong> care <strong>of</strong> elderly people and social servicesneed to be better developed, so that <strong>patients</strong> receive theappropriate care and support required.Transition careThe ABN fully supports the RCP’s young adult andadolescent initiative to improve healthcare outcomes forthose aged 16–24 years. Some neurologists alreadyundertake transition clinics <strong>with</strong> paediatric colleagues(in specialties such as epilepsy and neuromusculardiseases) but there is a need to increase the pr<strong>of</strong>ile <strong>of</strong>this type <strong>of</strong> specialist service and to ensure that it isappropriately supported by trusts and health boardsacross the UK.Working <strong>with</strong> other specialistsManaging acute neurological conditions involves<strong>working</strong> <strong>with</strong> acute and other medical specialists in themedical admissions unit (MAU) and during wardliaison to improve appropriateness <strong>of</strong> investigations,obtain early diagnosis and speed up discharge fromhospital by facilitating appropriate follow-up. There hasto be a close liaison <strong>with</strong> radiologists, intensivists andneurophysiologists, and the involvement <strong>of</strong>neurosurgery and neurorehabilitation. Neurologistshave an increasing role in stroke care together <strong>with</strong>stroke <strong>physicians</strong> and geriatricians. Neurologists alsowork <strong>with</strong> psychiatrists in dementia services.Long-term condition services need neurologists,neurorehabilitationists, geriatricians and palliative care<strong>physicians</strong>.Close liaison also exists between neurology and otherspecialties in the following areas: Parkinson’s disease(geriatrics), dementia (psychogeriatrics), higherfunction disorders (neuropsychiatry andneuropsychology), double vision and visual loss(ophthalmology), dizziness (ear, nose and throat,audiovestibular <strong>physicians</strong>), peripheral nerve and nerveroot disease (orthopaedics), inherited neurologicaldisease (clinical genetics), functional disorders(psychiatrists), pain teams and obstetric services.Working <strong>with</strong> GPs and GPwSIsCare for <strong>patients</strong> <strong>with</strong> LTNCs has traditionally beenbased in DGH or RNC outpatient clinics that are mainlyconsultant delivered, and more recently have had nursespecialist input. Newer networks <strong>of</strong> care are developing<strong>with</strong> the involvement <strong>of</strong> primary care, and neurologistsare key members <strong>of</strong> these networks. Better use needs tobe made <strong>of</strong> combined meetings, educational seminarsand clinical guidelines to underpin this network.5 Delivering a high-quality serviceWhat is a high-quality service?The ABN and the Neurological Alliance(www.neural.org.uk) are currently assessing whatoutcomes can be measured to reflect high-quality care.These have to be meaningful and applicable to allneurology units in England, Wales and NorthernIreland. Scotland has published clinical standards forC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 175


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>the neurological health services, 4 <strong>with</strong> implementation<strong>of</strong> these standards from 2010. The National Institute forHealth and Care Excellence (NICE) has already setquality standards for stroke and dementia.The framework is in part set out in ABN 3 and RCP 5documents and the main criteria would include: a patient-centred service timely referral (according to the waiting-time targetset out by individual home nations) and adherenceto existing NICE guidance involvement <strong>of</strong> a neurologist in assessing acuteneurological emergencies provision <strong>of</strong> appropriate follow-up access to clinical nurse specialists and therapists access to rehabilitation access to palliative care clear and up-to-date information available to<strong>patients</strong>.Maintaining and improving the quality <strong>of</strong> careExcellence should be maintained and deficienciesidentified and corrected through: service developments to deliver improved care leadership role for consultant neurologists inintroducing service change education and training constructive appraisal continuing pr<strong>of</strong>essional development clinical governance research regional and national work for the royal colleges,ABN, deaneries, Department <strong>of</strong> Health and BritishMedical Association, and as advisers to variouspatient support groups, as examples.Specialty and national guidelinesAssociation <strong>of</strong> British Neurologists’ guidelinesThe following are available at www.abn.org.uk:Neurology in the United Kingdom: numbers <strong>of</strong> clinicalneurologists and trainees (1996)Neurology in the United Kingdom: towards 2000 andbeyond (1997)Acute neurological emergencies in adults (2002)Levelling up (Neurological Alliance, 2002)The medical management <strong>of</strong> motor neurone disease – aUK perspective <strong>of</strong> current practice (2002)Academic neurology in the United Kingdom: threats,opportunities and recommendations (2003)Standards <strong>of</strong> care for people <strong>with</strong> neurological disorders(2004)Intravenous immunoglobulin in neurological diseases(2005)ABN guidelines for treatment <strong>of</strong> multiple sclerosis <strong>with</strong>B-interferon and glatiramer acetate (2009).NICE guidanceThe following are available at www.nice.org.uk:Alzheimer’s disease: donepezil, rivastigmine andgalantamine (replaced by TA111) (2001)Guidance on the use <strong>of</strong> riluzole (Rilutek) for thetreatment <strong>of</strong> motor neurone disease (2001)Beta interferon and glatiramer acetate for thetreatment <strong>of</strong> multiple sclerosis (2002)Multiple sclerosis: management <strong>of</strong> multiple sclerosis inprimary and secondary care (2003)Head injury: triage, assessment, investigation and earlymanagement <strong>of</strong> head injury in infants, children andadults (2007)The epilepsies: the diagnosis and management <strong>of</strong> theepilepsies in adults and children in primary andsecondary care (2004)Parkinson’s disease: diagnosis and management inprimary and secondary care (2006)Dementia: supporting people <strong>with</strong> dementia and theircarers in health and social care (2006)Natalizumab for the treatment <strong>of</strong> adults <strong>with</strong> highlyactive relapsing–remitting multiple sclerosis (2007)Neuropathic pain: the pharmacological management <strong>of</strong>neuropathic pain in adults in non-specialist settings(2010)Management <strong>of</strong> transient loss <strong>of</strong> consciousness in adultsand young people (2010)Headache: diagnosis and management <strong>of</strong> headaches inyoung people and adults (2012)The epilepsies: the diagnosis and management <strong>of</strong> theepilepsies in adults and children in primary andsecondary care (2012)Urinary incontinence in neurological disease (2012)Spasticity in children and young adults (2012).NICE quality standardsQuality standards for epilepsy and headache are underdevelopmentRCP guidelines and reportsThe following are available at www.rcplondon.ac.uk:Chronic spinal cord injury: management <strong>of</strong> <strong>patients</strong> inacute hospital settings (2008)176 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties NeurologyCare after stroke or transient ischaemic attack:information for <strong>patients</strong> and their carers (2008)Measuring clinical outcome in stroke: acute care (2008)Stroke: national clinical guideline for diagnosis andinitial management <strong>of</strong> acute stroke and transientischaemic attack (TIA) (2008)Spasticity in adults: management using botulinumtoxin: national guidelines (2009)Long-term neurological conditions: management at theinterface between neurology, rehabilitation andpalliative care (2008)Oral feeding difficulties and dilemmas: a guide topractical care, particularly towards the end <strong>of</strong> life(2010)Local adult neurology services for the next decade:report <strong>of</strong> a <strong>working</strong> party (2011).Scottish Intercollegiate Guidelines Network(SIGN) guidelinesThe following SIGN guidelines are available atwww.sign.ac.uk: Diagnosis and management <strong>of</strong> epilepsy in adults(2005) Management <strong>of</strong> <strong>patients</strong> <strong>with</strong> dementia (2006) Management <strong>of</strong> <strong>patients</strong> <strong>with</strong> stroke or TIA:assessment, investigation, immediate managementand secondary prevention (2008) Diagnosis and management <strong>of</strong> headache in adults(2008) Early management <strong>of</strong> head injury (2009) Management <strong>of</strong> <strong>patients</strong> <strong>with</strong> stroke: identificationand management <strong>of</strong> dysphagia (2010) Management <strong>of</strong> <strong>patients</strong> <strong>with</strong> stroke: prevention andmanagement <strong>of</strong> complications, and discharge planning(2010) Diagnosis and pharmacological management <strong>of</strong>Parkinson’s disease (2010).Departments <strong>of</strong> HealthThe Department <strong>of</strong> Health (England) published theNSF for long-term conditions in 2005 but this wasstopped after a damning mid-point review (see NationalAudit <strong>of</strong>fice and Public Accounts Committee reports);the Department <strong>of</strong> Health in England will now be underappropriate scrutiny to ensure that there are measurableimprovements in services for <strong>patients</strong> <strong>with</strong> LTNCs.The Scottish Government Health Department hasproduced its report 9 on Neurological health services inScotland and its findings show enormous variabilityacross its health boards. It now has a baseline fromwhich to monitor progress.Neurology service guidelines have not been produced bythe governments <strong>of</strong> Wales and Northern Ireland andthis needs to be rectified urgently.Specialty and national auditIndividually, neurologists participate in national auditprojects (stroke and epilepsy) and the ABN is <strong>working</strong>through the RCP Clinical Effectiveness Forum toestablish a system for collecting local and regional auditsand to implement a strategy for UK-wide projects.6 Clinical work <strong>of</strong> consultantsNeurologists should be involved in the acute care <strong>of</strong>people <strong>with</strong> neurological disorders 2,6 andshouldhavesufficient sessions to provide this through ward liaisonand attending the MAU and the accident andemergency department.How a consultant works in this specialtyInpatient workThis may take the form <strong>of</strong> ward rounds, ward liaisonand care <strong>of</strong> emergency admissions. Time may be spent<strong>working</strong> <strong>with</strong> MDTs, discharge planning, writingdischarge summaries and other patient-relatedadministration.Outpatient workThe number <strong>of</strong> outpatient clinics will depend on otherduties, in particular the amount <strong>of</strong> inpatient andemergency work. A 10-session job plan could have 3–4outpatient sessions. When consultants are expected tovisit more than one site, appropriate travel time must beallocated, included as <strong>working</strong> time, <strong>with</strong>in aprogrammed day-care centre activity.Clinics should be reduced by 25% if they are dedicatedtraining or teaching clinics.The recommended time allocated for each neurologicaloutpatient in a general neurology clinic is: 30 minutes per new patient for a consultant, 45minutes for a specialty registrar (StR) (years 1–3) 15 minutes per follow-up patient for a consultant or30 minutes for an StR (years 1–3).C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 177


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>The duration <strong>of</strong> consultation appointments in tertiarysubspecialist clinics will vary according to theconsultant/team involved and is likely to be longer thanfor general neurology clinics.Clinically related administrationA minimum <strong>of</strong> an additional 50% <strong>of</strong> time per clinic isincluded in direct clinical care for responses to referralsand administration relating to consultations.Balance <strong>of</strong> clinics, wards, acute andsubspecialty careThis will vary between neurologists, depending on theproportion <strong>of</strong> the <strong>working</strong> week spent in the RNC,DGH/NCs, or doing community clinics or at a regionalcentre. Most will have at least one specialist clinic perweek. Neurology beds are mainly located in RNCs, butlarger DGHs designated as NCs should be encouragedto have some dedicated neurology beds <strong>with</strong>appropriately skilled nursing and junior medical staff.Proportion <strong>of</strong> direct supervision/teamworkThe proportion <strong>of</strong> consultant-delivered activity hasincreased. Trainees should have regular meetings <strong>with</strong>their educational and clinical supervisors and the moredemanding delivery and monitoring <strong>of</strong> traineeeducation require timetabling through the job-planningprocess. All neurologists should be <strong>with</strong>in a team, butthe team structure will vary depending on the site(DGH/NC/RNC) <strong>of</strong> greatest clinical activity.Community-based workOver the last decade, clinical nurse specialists (CNSs)and GPwSIs have played an increasing role in themanagement <strong>of</strong> <strong>patients</strong> <strong>with</strong> a range <strong>of</strong> neurologicalconditions both in hospital and in the community.Average ratios <strong>of</strong> new:follow-up <strong>patients</strong> are on thewhole meaningless, particularly when caring for<strong>patients</strong> <strong>with</strong> LTNCs, and do not reflect quality <strong>of</strong> care.Specialist investigative and therapeuticproceduresThese are limited, <strong>with</strong> the exception <strong>of</strong> a botulinumtoxin injection. It may become more common forneurologists to have a role in the running <strong>of</strong>electroencephalography (EEG) and electromyography(EMG) clinics.Specialist on callThis may be a regional rota from the neurosciencescentre, or based more locally if this can be achieved.Other specialist activityMany neurologists will have regional or supra-regionalclinical responsibilities.7 Opportunities for integrated carePathways for a number <strong>of</strong> neurological conditionsalready exist (stroke, epilepsy, Parkinson’s disease,motor neuron disease and acquired brain injury) butthis is an area that requires further expansion.Neurologists should be given the flexibility in jobplanning to be able to develop integrated pathwaysthat extend outside secondary care, so that quality <strong>of</strong>care improves and clinic/hospital admissions arereduced.8 Workforce requirements for neurologyAt present there are 684 consultant neurologists inNHS practice in the UK, <strong>with</strong> 274 national trainingnumbers.To provide a comprehensive DGH neurology servicethat includes scheduled and unscheduled neurologicalcare, at least 3.6 whole-time equivalent (WTE)neurologists per 250,000 population are required – atotal <strong>of</strong> around 880 consultants in the UK. 2There is a need and increasing demand for 7-day24-hour expert services. This will be difficult to providefor neurology <strong>with</strong> the current consultant numbers –particularly at DGH level. It is unrealistic that allexisting DGHs will provide such a specialist neurologyservice; this should happen in larger DGHs <strong>with</strong> NCsand RNCs, <strong>with</strong> an absolute minimum number <strong>of</strong> 1neurologist per 70,000 population to cover one siteevery day <strong>of</strong> the week. If there aren’t enoughneurologists to allow that level <strong>of</strong> staffing, then therewill need to be a rationalisation <strong>of</strong> the number <strong>of</strong>hospitals that are able to admit, investigate and manage<strong>patients</strong> <strong>with</strong> neurological illness.The projected greater liaison <strong>with</strong> community servicesis also likely to be demanding on time. Time needs to bemade available through job planning to allow aneurologist to teach and supervise GPwSIs andcommunity nurses in a range <strong>of</strong> topics includingParkinson’s disease, multiple sclerosis and motorneuron disease, brain injury, headache and epilepsy.178 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties NeurologyAchieving key government targets for the delivery <strong>of</strong>high-quality services requires this expansion inconsultant number to: deliver services close to the patient’s home wherethis is possible. This will impact on health outcome(eg improving seizure control and so reducingsudden death in <strong>patients</strong> <strong>with</strong> epilepsy) provide continuous cover, eg thrombolysis andhospital at night deal <strong>with</strong> changing population demographics andresultant increase in chronic neurological illness assess, administer and monitor new technologies, egnew drugs for multiple sclerosis.9 <strong>Consultant</strong> work programmeThere is no fixed job plan for a consultant neurologist.The structure <strong>of</strong> the <strong>working</strong> week will depend on howthe particular service/network is organised. For aneurologist covering a DGH <strong>with</strong> minimal support, thepost should have no more than three clinics per week; inlarger departments neurologists could do four or fiveclinics per week, depending on other duties.As guidance, in England, Scotland and NorthernIreland, a typical 10-session job plan split betweendirect clinical care (DCC) and supporting pr<strong>of</strong>essionalactivities (SPA) should be a 7.5/2.5 (DCC/SPA). InWales the job plan is split 7.0/3.0. For university-basedclinicians (academic) this will be different again, andwill normally contain no more than two clinics, one <strong>of</strong>which will be a specialist clinic. It is recognised that thestructure <strong>of</strong> a 10-session job plan will vary according toindividual and local need for clinics, liaison duties,research, training and teaching dutiesThe training post numbers in neurology have notchanged from 2011. An expansion in training posts isneeded to provide the required staffing levels for aconsultant-led DGH service.The key elements <strong>of</strong> a job plan are shown in Table 1.10 Key points for commissioners in EnglandThe recent changes in NHS England provide anopportunity to correct major deficiencies that exist inthe care <strong>of</strong> <strong>patients</strong> <strong>with</strong> neurological conditions:Neurology will be part <strong>of</strong> a strategic clinical network(mental health, dementia and neurological conditions)to be operational from April 2013 and clinicalleadership will be provided by Dr David Bateman,consultant neurologist and national clinical director forchronic disability and neurological conditions.At the present time there is uncertainty regarding whichneurology services the NHS Commissioning Board(NHS CB) will assume responsibility for, and what willbe for more local clinical commissioning groups(CCGs). As demonstrated by the recent National AuditOffice and Public Accounts Committee reports onneurological services, the absence <strong>of</strong> national leadershipand local accountability were central to the failedimplementation <strong>of</strong> the NSF for LTNCs. If this divisionbetween specialist and general neurologicalcommissioning is to work in the best interest <strong>of</strong> <strong>patients</strong>under the new system, the NHS CB must providemaximum support to CCGs to meet their directneurology commissioning responsibilities.In this context, the new National clinical director forchronic disability and neurological conditions will havea key role to play in enabling the effectivecommissioning <strong>of</strong> neurological services at national andlocal level. Developing commissioning tools andoutcome measures for inclusion in accountabilityframeworks must represent key priorities from theoutset <strong>of</strong> their appointment. Similarly, the strategicclinical network for mental health, dementia andneurological conditions must be properly resourced t<strong>of</strong>acilitate seamless care for individuals interacting <strong>with</strong>both specialised and general neurology services.The key points are as follows:1 Commissioning groups for neurology <strong>with</strong> a strongclinical representation should be established todevelop a comprehensive local and regionalneurology service over the next 10-year period.2 Resources should be provided to increaseneurology sessions in DGHs to improve acute care(unscheduled) <strong>of</strong> neurological <strong>patients</strong> (in DGHs,NCs and RNCs).3 The importance <strong>of</strong> the partnership between theDGH/NC and RNC must be recognised.4 Commissioning <strong>of</strong> health- and social care forneurological <strong>patients</strong> should be linked.5 Alternative community settings for elements <strong>of</strong>neurological long-term care should be considered.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 179


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Main elements <strong>of</strong> a consultant job planDirect clinical careSession(s)/weekOutpatient clinic (including admin) (1.5 sessions each) 4.5–7.5Ward round 0.0–1.0Ward liaison 0.0–5.0MAU ward round 0.0–5.0Multidisciplinary meetings, eg <strong>with</strong> clinical nurse specialists (CNSs), neuroradiologists, neuropathologists,neuropsychologistsOn-call dutiesTravel time0.5–1.0VariableVariableSupporting pr<strong>of</strong>essional activities (SPAs)CPD/audit/appraisal/revalidation 1.5Teaching/training 0.0–1.0Participation in research, eg National Institute for Health Research (NIHR) 0.0–1.0Service development 0.0–1.0Other NHS responsibilities, medical director, clinical director, lead consultant in specialty, clinical tutorExternal duties, work for deaneries, royal colleges, specialist societies, Department <strong>of</strong> Health, trust/healthboard or other government bodiesBy local agreementBy local agreement6 Neurology provision has a shortage and thereforeneeds to expand to provide an acceptable quality <strong>of</strong>service.7 Local geographical, population and manpowervariations mean that different models <strong>of</strong> servicedelivery must be used.8 Payment by results tariffs (in England) foroutpatient and inpatient work require carefulresearch and should be calculated to allowhigh-quality services to be maintained anddeveloped.9 Improved resources for neurological rehabilitationare urgently needed.10 An increase in training numbers is needed to meetconsultant manpower requirements.References1 Macdonald BK, Cockerell OC, Sander WAS, Shorvon SD.The incidence and lifetime prevalence <strong>of</strong> neurologicaldisorders in a prospective community-based study in theUK. Brain 2000;123:665–76.2 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians and Association <strong>of</strong> BritishNeurologists. Local adult neurology services for the nextdecade: report <strong>of</strong> a <strong>working</strong> party. London: RCP/ABN,June 2011.3 Association <strong>of</strong> British Neurologists. Response to the NSFfor long-term conditions. London: ABN, 2007.4 NHS Quality Improvement Scotland. Clinical standards –October 2009: neurological health services. Edinburgh:NHSQIS, 2009. www.nhshealthquality.org [AccessedMay 2013].5 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians, National Council forPalliative Care and British Society <strong>of</strong> RehabilitationMedicine. Long-term neurological conditions:management at the interface between neurology,rehabilitation and palliative care. Concise guidance togood practice, no 10. London: RCP, 2008.6 Association <strong>of</strong> British Neurologists. Acute neurologicalemergencies in adults. London: ABN, 2002.7 National Audit Office. Services for people <strong>with</strong>neurological conditions, 2011. www.nao.org.uk/services-for-people-<strong>with</strong>-neurological-conditions/[Accessed May 2013].8 Public Accounts Committee reports on services forpeople <strong>with</strong> neurological conditions, 2012. www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/news/neuro-report-/ [Accessed May 2013].9 Healthcare improvement Scotland. Neurological healthservices in Scotland, 2012.www.healthcareimprovementscotland.org180 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Nuclear medicineNuclear medicineDr John Buscombe MBBS MD FRCP FRCR <strong>Consultant</strong> physician nuclear medicineDr Sabina Dizdarevic MD MSc FRCP <strong>Consultant</strong> in nuclear medicinePr<strong>of</strong>essor Val Lewington BM MSc FRCP FRCR Pr<strong>of</strong>essor <strong>of</strong> nuclear medicineDr Brian Neilly MBChB MD FRCP FRCR <strong>Consultant</strong> physicianDr Liz Prvulovich MD FRCP FASNC FEBNM <strong>Consultant</strong> physician nuclear medicineDr Andrew Scarsbrook BMedSci BMBS FRCR Nuclear medicine physician1 Description <strong>of</strong> the specialtyNuclear medicine uses radioactive materials fordiagnosis, treatment and research. Nuclear medicineinvestigations detect early physiological changes thatoccur in response to disease, and provide uniquefunctional information to diagnose and support themanagement <strong>of</strong> <strong>patients</strong> <strong>of</strong> all ages in many medicalareas including oncology, cardiology, nephrourology,orthopaedics, rheumatology and neuropsychiatry.Increasingly, nuclear medicine data are fused<strong>with</strong> anatomical scans to improve the specificityand sensitivity <strong>of</strong> complementary imagingmodalities.The range <strong>of</strong> diagnostic nuclear medicine investigationsis expanding rapidly. Tracers based on receptor-specificligands, monoclonal antibodies and small peptides arenow available for tissue characterisation at a molecularlevel, contributing to the investigation <strong>of</strong> movementdisorders, schizophrenia, Alzheimer’s disease, theunstable coronary plaque and thromboembolicdisease.Advances in tumour targeting have led to a parallelexpansion in unsealed source therapy usinghigh-activity, radiolabelled drugs for cancer treatment.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralNuclear medicine services are hospital based, <strong>with</strong>additional provision <strong>of</strong> positron emissionimaging–computed tomography (PET-CT) in someareas via mobile scanners. Service delivery varies to suitlocal population size, casemix and degree <strong>of</strong>centralisation. 1,2 Small departments undertaking alimited range <strong>of</strong> diagnostic investigations follow anoutpatient clinic model and are <strong>of</strong>ten sited <strong>with</strong>inradiology departments. Large units <strong>of</strong>fering acomprehensive range <strong>of</strong> diagnostic procedures, bonedensitometry, outpatient clinics and radionuclidetherapy require day-care and dedicated inpatientfacilities.Diagnostic nuclear medicine procedures are performedeither by specialist nuclear medicine practitioners or bymultiple individual practitioners responsible for specificservice components allied to their main specialty.Examples <strong>of</strong> the latter include system-specificradiologists and cardiologists. Where the service isfragmented, it is essential to have at least one specialisttrained to Certificate <strong>of</strong> Completion <strong>of</strong> Training (CCT)level (or on the specialist register) in nuclear medicineto ensure consistent development across the fullspectrum <strong>of</strong> nuclear medicine practice.Diagnostic services are required in most acute hospitals.Service configuration usually follows a ‘hub-and-spoke’design, linking large teaching hospital centres <strong>with</strong>smaller, local departments. Specialist services andinpatient facilities are provided in the central unit andconsultants may undertake sessions in central andoutreach hospitals. Nuclear medicine consultants <strong>with</strong>particular expertise in cardiology, oncology, PET-CTand radionuclide therapy provide advice and receivetertiary referrals from other centres.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcarePatient preference is central to service delivery.However, due to legal constraints all proceduresinvolving radiation exposure must be justified and <strong>of</strong>tenthe need to order the required radiopharmaceuticals,which may not be available every day, means that theseC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 181


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>scans are <strong>of</strong>ten planned in advance. However, someunits have limited instant access to some tests such aslung scintigraphy. Direct access to services <strong>with</strong>out areferral from a medical or IR(ME)R-approvedpractitioner is, therefore, inappropriate for bothpractical and safety reasons.The majority <strong>of</strong> diagnostic nuclear medicineinvestigations are undertaken as outpatient procedures,whereas high-activity radionuclide therapy may requireinpatient admission for between 1 and 7 nights in asingle room <strong>with</strong> separate washing and toilet facilities.Written information is required for all procedures andis, ideally, developed in collaboration <strong>with</strong> patientrepresentatives. The Joint Specialty Committee forNuclear Medicine and the British Nuclear MedicineSociety have developed central information resourcesfor <strong>patients</strong> and their carers. The significance <strong>of</strong> testresults and potential implications for management areusually discussed <strong>with</strong> <strong>patients</strong> by their referringclinician.4 Interspecialty and interdisciplinaryliaisonMultidisciplinary team <strong>working</strong>Non-medical personnel are essential to routine nuclearmedicine service provision. The skill mix varies betweendepartments but will usually include physicists andother clinical scientists, medical technical practitioners,radiographers, radiopharmacists and nuclear medicinenurse specialists. Play specialists and cardiac technicianscontribute to specialist services in centres <strong>with</strong> a highpaediatric or cardiac workload. Provision <strong>of</strong> a medicalphysics expert and a radiation protection adviser is alegal requirement.Nuclear medicine clinicians liaise closely <strong>with</strong> mostother specialties and are <strong>of</strong>ten core members <strong>of</strong> cancermultidisciplinary team (MDT) meetings. Review <strong>of</strong>nuclear medicine imaging should be undertaken byappropriately trained specialists who are able to provideadvice reflecting new information arising from MDTdiscussions. The <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP) haspublished new guidance for nuclear medicine<strong>physicians</strong> <strong>working</strong> <strong>with</strong>in MDTs.Most nuclear medicine specialists undertakeradionuclide therapy and many are the lead clinicians injoint clinics managing benign and malignant disease.5 Delivering a high-quality serviceA high-quality service is patient centred and producesaccurate results in a timely manner in accordance <strong>with</strong>explicit service standards. Nuclear medicine servicesshould be led by a specialist trained to CCT level (or onthe specialist register), or equivalent, in nuclearmedicine. Service quality is jeopardised in hospitalswhere there is no sessional commitment to nuclearmedicine, particularly if a small nuclear medicinecaseload is divided between a large numbers <strong>of</strong>consultants, diluting individual experience. The nuclearmedicine physician liaises closely <strong>with</strong> scientists andclinical colleagues to ensure that new evidence-basedtechniques are introduced safely.Reciprocal rota commitments <strong>with</strong> colleagues in otherunits are recommended to avoid pr<strong>of</strong>essional isolationfor consultants <strong>working</strong> single-handedly. Telemedicinelinks improve communication between large andsmaller departments and facilitate audit but are not asubstitute for local clinical involvement. Scan readingand issuing reports is only part <strong>of</strong> the role <strong>of</strong> the nuclearmedicine specialist. As many <strong>of</strong> the studies performedare not well known by the general medical pr<strong>of</strong>essionproviding an expert opinion and guidance is alsoessential.The facilities required to deliver a high-quality serviceinclude: dedicated patient waiting areas to separate <strong>patients</strong>who have received radiopharmaceuticals from<strong>patients</strong> and carers not receiving them separate area for administration <strong>of</strong>radiopharmaceuticals dedicated toilet facilities which will need to comply<strong>with</strong> trust’s disabled access and personal dignityrequirements examination rooms and quiet counselling room fordiscussion <strong>with</strong> any patient, including any pregnantand breastfeeding women, appropriate to thecasemix secure radiopharmaceutical storage area area for image analysis data-reporting room educational and library area separate paediatric waiting or play area, asappropriate cardiac stressing facility – this may be shared <strong>with</strong>cardiology if it is organisationally more appropriate182 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Nuclear medicine imaging equipment appropriate for the casemix,which should be maintained to publishedspecifications radiation protection measures to comply <strong>with</strong> allrelevant legislation <strong>of</strong>fice space for other staff information technology, access to electronicpatient record (EPR), results reporting andprescription analysis, and cost tabulation, PACSfacilities.If the department uses PET-CT, single-photon emissiontomography–computed tomography (SPET-CT) andpositron emission tomography–magnetic resonance(PET-MR), additional facilities may be required for staffand <strong>patients</strong>. Paediatric services may require areas forrecovery after general anaesthesia.Inpatient radionuclide treatment must take place in adedicated facility <strong>with</strong> appropriate monitoringequipment and shielding for radiation protection, andbe performed by correctly trained medical andnon-medical staff. This may involve a dedicated area<strong>with</strong>in the nuclear medicine department, interventionalradiology and dedicated ward areas.Maintaining and improving the quality<strong>of</strong> careAll procedures are undertaken in accordance <strong>with</strong>written departmental standard operating procedures(SOPs); where possible these procedures andprotocols should be derived from the BNMS orEuropean guidelines. 3–10 The expected expansion <strong>of</strong>nuclear medicine services <strong>with</strong>in cancer centres willsupport cross-specialty liaison and shared access topurpose-built, shielded facilities for radionuclidetherapy. Improving access to radionuclide therapythroughout the UK will require close MDT cooperationand mentorship <strong>of</strong> individuals <strong>working</strong> in small centres.Nuclear medicine specialists provide expert advice toMDTs and tumour <strong>working</strong> groups <strong>with</strong>in cancernetworks about radionuclide treatment options for<strong>patients</strong> <strong>with</strong> malignant disease.Service developments to deliver improvedpatient careThe 2003 intercollegiate report recommendedprioritising nuclear medicine specialist support for allUK cancer networks in a ‘hub-and-spoke’ model. 2Central (hub) functions include protocol development,provision <strong>of</strong> comprehensive diagnostic services andradionuclide therapy. Smaller (spoke) departmentsundertake a limited range <strong>of</strong> radionuclide imaging andtherapy for benign disease. Access to PET-CT hasimproved following implementation <strong>of</strong> keyrecommendations for the development <strong>of</strong> PET servicesin England. 5 Mobile service provision continues as aninterim measure probably until 2015. Planning <strong>of</strong> howto replace this mobile provision should commence 2years before any transfer <strong>of</strong> work from a mobile to astatic site.A recent review published by the British Institute <strong>of</strong>Radiology 11 hasshownamassivevariationinprovision<strong>of</strong> radionuclide therapy in cancer <strong>with</strong> <strong>patients</strong> in thenorth west and London being well served whileprovision in the rest <strong>of</strong> the country is <strong>of</strong>tenlimited.Education and trainingThe small number <strong>of</strong> UK consultants results insubstantial education commitments to nuclearmedicine trainees, specialty registrars in otherdisciplines and non-medical staff. Training curricula,standards and competency assessment measures havebeen developed to allow non-medical healthcare staff toundertake extended roles, thereby improving localaccess to nuclear medicine. A long-term issue has beenthe need for the modern nuclear medicine trainee toreceive adequate training in cross-sectional imaging.Although there have been examples <strong>of</strong> good localinitiatives, further work is needed to ensure thatdelivery <strong>of</strong> such high-quality relevant training is seennationwide. It is hoped that such a programme will berolled out in 2013–14.<strong>Consultant</strong>s are expected to undertake at least 50 hours<strong>of</strong> continuing pr<strong>of</strong>essional development (CPD) perannum and may take a leading role in clinicalgovernance. Work plans should include protected timefor clinical audit, which will <strong>of</strong>ten be undertaken atregional or national level.Research – clinical duties and basic scienceNuclear medicine techniques are used extensively inmedical research. The 2003 college censusindicated that 40% <strong>of</strong> consultants held at leastpart-time academic contracts. 12 The pressing need todevelop academic molecular imaging is addressed<strong>with</strong>in current proposals for curriculum and trainingreview.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 183


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Local management dutiesMany nuclear medicine consultants have managerialduties as heads <strong>of</strong> departments and statutoryresponsibilities <strong>with</strong> respect to the Administration <strong>of</strong>Radioactive Substances Advisory Committee (ARSAC)and the Medical Application <strong>of</strong> Radioactive Substances(MARS) regulations. Many also contribute to the work<strong>of</strong> radiation protection and research ethics committees.Regional and national workThe small number <strong>of</strong> nuclear medicine consultantsnationally results in strong commitments to externaleducational and pr<strong>of</strong>essional leadership. They will <strong>of</strong>tentake a leadership role <strong>with</strong> their region. It would beexpected that most consultants in nuclear medicinewould be involved in national committees at some pointin their pr<strong>of</strong>essional life.Specialty and national guidelinesSpecialty guidance for nuclear medicine is summarisedin Table 1.6 Clinical work <strong>of</strong> consultantsHow a consultant works in this specialtyNuclear medicine is a consultant-delivered service.Specialists are responsible for justifying, supervisingand reporting diagnostic investigations and foradministering unsealed source therapy. At present, fewnuclear medicine departments provide on-call nuclearmedicine diagnostic services but pressure for extendedhours <strong>working</strong> is anticipated. The supply <strong>of</strong>radiopharmaceuticals outside normal <strong>working</strong> hoursmay be problematic. Centres that undertake inpatienttherapy provision must ensure consultant on-callavailability.Typical time requirements for completion <strong>of</strong> differentprocedures are suggested in Table 1. These allow forreferral vetting, patient assessment, manipulation <strong>of</strong>drug therapy where appropriate, procedure supervision,discussion <strong>with</strong> <strong>patients</strong> and colleagues, review <strong>of</strong> otherimaging/case notes and authorisation <strong>of</strong> final reports.Also reporting <strong>of</strong> imaging should not be in isolation butreference made to previous imaging <strong>of</strong> the patientavailable on PACS.7 Opportunities for integrated careNuclear medicine consultants work closely <strong>with</strong>referring clinicians to ensure timely access to diagnosticinvestigations, in particular to ensure that studies areperformed <strong>with</strong>in the required guidelines. However,recent problems <strong>with</strong> the production <strong>of</strong> theradio-isotopes themselves have meant prolonged waitsfor some specialised studies. This shortage situation isexpected to continue till 2018. The specialty hasresponded quickly to meet the requirements <strong>of</strong>‘one-stop’ outpatient and acute medical assessmentunits. Integrated care <strong>with</strong>in the hospital setting is wellestablished for <strong>patients</strong> undergoing targetedradionuclide therapy, <strong>with</strong> close cross-specialtycollaboration being reinforced by MDT <strong>working</strong>.Shared care <strong>with</strong> palliative care and community teams isincreasing to ensure supervision close to home afterradionuclide treatment. The use <strong>of</strong> hybrid imaging(PET-CT, PET-MR and SPRCT-CT) <strong>of</strong>ten means asingle set <strong>of</strong> images is all that is needed for diagnosis, so<strong>of</strong>fering a ‘one-stop’ diagnostic service. This has <strong>of</strong>tenmeant close <strong>working</strong> <strong>with</strong> specialist nurses in bothoncology and non-oncological specialties. Specialarrangements allow specialist nurses to requestnuclear medicine studies and remain IR(ME)Rcompliant8 Workforce requirements for the specialtyThere are approximately 230 individuals on the GeneralMedical Council’s (GMC’s) specialist register fornuclear medicine. The 2011 RCP census listed nuclearmedicine as the main specialty <strong>of</strong> 72 college members(64 in England and 2 in Scotland), a fall <strong>of</strong> 2 since 2009.However, not all <strong>of</strong> these people work full time in thespecialty. 12 The picture is complicated by thecontribution <strong>of</strong> specialists in other disciplines,particularly radionuclide radiology, to nuclear medicineservice delivery, many <strong>of</strong> whom spend only a fewsessions per week in the specialty. The 2000Intercollegiate Standing Committee in NuclearMedicine survey identified about 190 trusts thatprovided nuclear medicine services, <strong>with</strong> an average <strong>of</strong>2.2 consultants per trust, 2 equating to approximately400 consultants. The survey did not indicate the timeallocation to nuclear medicine, however, and sometrusts failed to identify any medical time at all for theservice. The RCR census <strong>of</strong> 2011 13 identified 140radiologists as providing a radionuclide service. Thismay include some double counting <strong>with</strong> the RCPcensus. Also those who report radionuclide studies butdo not have any dedicated sessions may not havemarked radionuclide radiology as a main area <strong>of</strong>subspecialty interest.184 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Nuclear medicineTable 1 Guidelines for reporting times for nuclear medicine studies. Please note the times are additive so if thereis a routine planar imaging and SPET-CT in the same patient it is important to add the times taken for bothimaging modalitiesTime required (min)Non-training environmentTraining environmentProcedureRoutine non-imaging studies,planar imaging and bonedensitometryTomographic imaging (SPET andSPET–CT)10–15 13–2015–20 20–30Complex procedures and image 30–40 40–50co-registration studies ∗PET 30–45 ∗ 45–60 ∗∗Stressing before cardiac imaging,including prior assessment andadvice on drug treatment25 30Outpatient thyroid therapyNew patient 45 60Follow-up 15 20Inpatient therapy and otheroutpatient therapiesVariable according to length <strong>of</strong> patient stay and amount <strong>of</strong> careshared <strong>with</strong> other specialties. On average, allow 40 min for apretreatment, 60–120 min on day <strong>of</strong> administration and 15 min perday per patient on subsequent days or follow-up visitsMultidisciplinary meetings ∗∗∗Preparation 60–240 60–240Presentation 60–240 60–240CT, computed tomography; PET, positron emission tomography; SPET, single-photon emission tomography.∗ This would include most paediatric studies.∗∗ In <strong>patients</strong> <strong>with</strong> lymphoma multiple studies may need to be viewed and quantification performed.∗∗∗ These may vary in length and complexity from a few <strong>patients</strong> per month to over 100 <strong>patients</strong> every week.An allocation <strong>of</strong> 300–350 whole-time equivalent (WTE)consultants in the UK was proposed 12 equating to about100–150 WTE nuclear medicine specialists <strong>with</strong>in hubslinked to cancer centres and 200–250 WTE nuclearmedicine specialists or radionuclide radiologists in thespokes.Thisnumberisregardedastheminimumrequired to manage increasing workload complexityand rising commitments to MDT participation. As allexisting training places are linked to expectedretirements, there is no training capacity for consultantexpansion. The 2011 RCP census indicated that a 5%per annum increase in current consultant WTEnumbers would be required to meet European WorkingTime Directive targets 14 and manage current workload.Twenty-two per cent <strong>of</strong> nuclear medicine consultantswill reach the age <strong>of</strong> 65 years <strong>with</strong>in the next 10 years. 14Current training numbers for nuclear medicine andradionuclide radiology (10 per annum) are justsustainable but do not allow for early retirements.Workforce planning will need to take into accountchanges in <strong>working</strong> practice, prospective cover forcolleagues and an increase in part-time work for periods<strong>of</strong> an individual’s career. <strong>Consultant</strong> expansion will beC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 185


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>necessary to accommodate proposals for 7-day serviceprovision. A significant increase in allied pr<strong>of</strong>essions(physicists, radiographers, medical technologists,radiopharmacists and administrative staff) will berequired to support this change.9 <strong>Consultant</strong> work programme/specimenjob plan<strong>Consultant</strong> work programmes will vary according tohospital size and range <strong>of</strong> nuclear medicine servicesprovided. Fixed commitments include reportingsessions, outpatient clinics, special procedures andMDT meetings. Additional time is required forpaediatric imaging and cardiac stress testing. Dutiessuch as administrative work, teaching and training areconsidered flexible commitments. The figures inTable 2 are an average guide and assume uninterruptedclinical activity. These new centres should be outsideLondon and the north west and provide for treatment<strong>of</strong> both benign and malignant conditions.10 Key points for commissioners1 Nuclear medicine investigations detect functionalchanges that occur early in disease, allowingprompt diagnosis and accurate, cost-effectiveassessment <strong>of</strong> treatment response.2 Demand for nuclear medicine services isincreasing, particularly in cancer diagnosis,cardiology and neuropsychiatry. The majority <strong>of</strong>diagnostic nuclear medicine investigations areundertaken as outpatient procedures.3 Services should be commissioned only fromdepartments that demonstrate compliance <strong>with</strong>statutory requirements and are led by a certificatedTable 2 <strong>Consultant</strong> job planProgrammedActivity Workload activities (PAs)Direct clinical careGeneral nuclear medicine Depends on casemix 2–3Myocardial perfusion stressing 8 <strong>patients</strong> 1Myocardial perfusion reporting 8 <strong>patients</strong> 0.5PET-CT imaging and reporting 8 <strong>patients</strong> 1SPET-CT imaging and reporting 8 <strong>patients</strong> 1X-ray/MDT meetings 2 <strong>patients</strong> per week 0.5–2Inpatient therapy 2 <strong>patients</strong> 1Outpatient clinics 3 new <strong>patients</strong> + 7 follow-up 1Outpatient therapy ∗ 4 <strong>patients</strong> 0.5Clinical administration Internal cover arrangements † 0.5–1Supporting pr<strong>of</strong>essional activitiesWork to maintain and improve healthcare qualityOther NHS responsibilities †External duties †Education and training, appraisal, servicedevelopment, audit, governance, CPD, revalidation,research, departmental managementeg medical director, clinical director, lead localclinician, educational supervisor, etceg work for deaneries, royal colleges, specialistsocieties, Department <strong>of</strong> Health, governmentalbodies, etc2.5Variable by localarrangementVariable by localarrangement∗ Allows time for consent and further discussion prior to treatment.† These programmed activities are subject to local negotiation.186 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Nuclear medicine(ARSAC) clinician trained to CCT level (orequivalent) in nuclear medicine.4 Clinical evaluations should be made byappropriately trained staff who demonstrate andmaintain competence in nuclear medicine orradionuclide radiology imaging.5 Where NICE guidance is available (chest pain,cancer pathways) providers should demonstratesufficient capacity to comply <strong>with</strong> thecommissioned activity.6 A ‘hub-and-spoke’ model for service delivery isencouraged. Providers should demonstrate thatservices are patient centred and that appropriateclinical and imaging data transfer facilities areavailable.7 Nuclearmedicineexpertadviceshouldbeavailableat MDT meetings in compliance <strong>with</strong> cancerstandards for diagnostic and therapeuticintervention decisions.8 General diagnostic nuclear medicine may beincluded in overall imaging activity. Providersshould demonstrate indicative clinical pathways todemonstrate appropriate diagnostic serviceutilisation.9 Outpatient therapy for benign disease such ashyperthyroidism may be available in smalldepartments if local skills are available.10 There needs to be provision for expected expansion<strong>of</strong> nuclear medicine into new diagnostic areas suchas amyloid imaging for the diagnosis <strong>of</strong> earlyAlzheimer’s dementia.11 High-activity radionuclide cancer treatment shouldbe provided by tertiary centres attracting sufficientnumbers <strong>of</strong> <strong>patients</strong> to provide treatment in MDTs.Radionuclide therapy may require inpatientadmission to a dedicated facility <strong>with</strong> radiationprotection shielding. These new centres should beoutside London and the north west and provide fortreatment <strong>of</strong> both benign and malignantconditions.References1 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Nuclear medicine: provision<strong>of</strong> clinical service. Working party report. London: RCP,1998.2 Intercollegiate Standing Committee on NuclearMedicine. Nuclear medicine and radionuclide imaging:a strategy for provision in the UK. London:RCP,2003.3 British Nuclear Medicine Society. Clinical procedureguidelines. www.bnms.org.uk/bnms-generic4 European Association <strong>of</strong> Nuclear Medicine. Scientificguidelines. www.eanm.org/scientific info/guidelines/guidelines intro.php?navId=545 Department <strong>of</strong> Health. A framework for the development<strong>of</strong> positron emission tomography (PET) services inEngland. London: DH, 2005.6 Joint <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians Training Board.Specialist training curriculum for nuclear medicine.www.jrcptb.org.uk/specialties/ST3-SpR/Documents/2010%20Nuclear%20Medicine%20Curriculum.pdf7 National Institute for Health and Care Excellence.Myocardial perfusion scintigraphy for the diagnosis andmanagement <strong>of</strong> angina and myocardial infarction. NICEtechnology appraisal guidance 73, 2003. www.nice.org.uk/guidance/TA738 Anagnostopoulos C, Harbinson Mm, Kelion A, et al.Procedure guidelines for radionuclide myocardialperfusion imaging. Heart 2004;90(suppl 1):1–10.9 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Radioiodineinthemanagement <strong>of</strong> benign thyroid disease: clinical guidelines.London: RCP, 2007.10 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Guidelines for themanagement <strong>of</strong> thyroid cancer, 2nd edn. London: RCP,2007.11 British Institute <strong>of</strong> Radiology. Molecular radiotherapy inthe UK: Current status and recommendations for furtherinvestigation. London: British Institute <strong>of</strong> Radiology,2010.12 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> theUnited Kingdom. Census <strong>of</strong> consultant <strong>physicians</strong>in the UK, 2002: data and commentary. London:RCP,2003.13 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Radiologists. Clinical radiology UKworkforce report 2011. London: RCR, 2011.14 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> theUnited Kingdom. Census <strong>of</strong> consultant <strong>physicians</strong> andmedical registrars in the UK, 2011: data and commentary.London: RCP, 2012.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 187


2 Specialties Palliative medicinePalliative medicineDr Bee Wee MBBCh MRCGP FRCP PhD <strong>Consultant</strong> and senior clinical lecturer inpalliative medicineDr Stephanie Gomm MBChB FRCP MD <strong>Consultant</strong> palliative medicine1 Description <strong>of</strong> the specialtyPalliative medicine, recognised in the UK as a medicalspecialty in 1987, is defined as ‘the study <strong>of</strong> <strong>patients</strong><strong>with</strong> active, progressive, far-advanced disease, for whomthe prognosis is limited and the focus <strong>of</strong> care is thequality <strong>of</strong> life’. Palliative <strong>physicians</strong> work <strong>with</strong>inspecialist palliative care teams, assessing and treating<strong>patients</strong> <strong>with</strong> difficult symptoms and complexpsychosocial and spiritual problems. The specialistsociety for palliative medicine <strong>physicians</strong> in the UK isthe Association for Palliative Medicine <strong>of</strong> Great Britainand Ireland (APM) (www.apmonline.org).Traditionally, most <strong>patients</strong> referred for palliative carehave advanced cancer. 1 More <strong>patients</strong> <strong>with</strong> end-stageprogressive non-malignant diseases are now beingreferred to specialist palliative care, from 13.6% in2006–7 2 to 17% in 2010–11. 1 Since 2000, the moststriking increases are in out<strong>patients</strong> (8% to 24%),hospital support (6% to 20%) and day therapy (5% to17%). For specialist palliative care inpatient units, theproportion <strong>of</strong> <strong>patients</strong> <strong>with</strong> a diagnosis other thancancer has increased from 3% to 11%, and the lowestincrease is for community settings from 4% to 10%.Inequity <strong>of</strong> access to specialist palliative care bydiagnosis, geography, age and ethnicity remains.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceSpecialist palliative care services include some or all <strong>of</strong>the components shown in Table 1. These are delivered bymultipr<strong>of</strong>essional teams who may come from differentorganisations <strong>with</strong>in the National Health Service(NHS) or voluntary sector. These services are usuallypart <strong>of</strong> supportive and palliative care networks (<strong>with</strong>incancer networks) and/or end-<strong>of</strong>-life care networks.Arrangements vary to reflect local structures andneeds. Relationships between palliative care networksand cardiac and renal networks are developing.Table 1 Components <strong>of</strong> specialist palliative careservicesClinicalInpatient specialistpalliative careCommunity palliative careteamsHospital palliative careteamsDay therapy servicesOutpatient clinicsAcademicEducation and trainingprogrammes/centresResearch groups anddepartmentsSources <strong>of</strong> referralIn 2007–8, 3 referrals to specialist palliative care camefrom: GPs or district nurses (28%) hospital doctors (34%) other specialist palliative care teams (16%).Patients are referred when specialist palliative careexpertise is needed in: symptom management management <strong>of</strong> complex psychosocial and spiritualissues terminal care decision making in uncertain progressive situations.Sometimes one-<strong>of</strong>f consultations are required. More<strong>of</strong>ten, ongoing shared care is helpful. Referrals may betriggered by <strong>patients</strong>, families or other pr<strong>of</strong>essionals.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareA patient-centred focus is fundamental to palliative carepractice: helping <strong>patients</strong> to express their wishes andachieve their preferences in relation to symptommanagement and end-<strong>of</strong>-life care, <strong>with</strong>in amulticultural context.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 189


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>National strategies to promote patient-centredcare for end-<strong>of</strong>-life care include: End<strong>of</strong>lifecarestrategy(England), 4 Living and dying well (Scotland), 5 thepalliative and end <strong>of</strong> life care strategy (Northern Ireland) 6and implementation <strong>of</strong> the Sugar Report (Wales). 7Resources for patient/carer education and supportinclude: Help the Hospices (www.hospiceinformation.info) The National Council for Palliative Care (NCPC)(www.ncpc.org.uk) Macmillan Cancer Support(www.macmillan.org.uk) Maggie’s Cancer Caring Centres(www.maggiescentres.org) National End <strong>of</strong> Life Care Programme(www.end<strong>of</strong>lifecareforadults.nhs.uk) healthtalkonline (www.healthtalkonline.org).User involvement occurs at local and regional levels.Electronic palliative care coordinating systems(EPaCCS) have been piloted in England and are nowbeing implemented across the country <strong>with</strong> a nationallyapproved standard (Information Standard Board) for itscore content. 8 Dying Matters, a national coalition inEngland, is promoting public awareness <strong>of</strong> dying, deathand bereavement (www.dyingmatters.org). Patients andcarers are becoming more involved in education,research and service evaluation.4 Interspecialty and interdisciplinary liaisonMultipr<strong>of</strong>essional specialist palliative care teamsIntegrated and flexible team<strong>working</strong> across pr<strong>of</strong>essionalboundaries is essential. See section 6 for the role <strong>of</strong>consultants in palliative medicine. Other essential teammembers include: clinical nurse specialists: provide assessment,support, monitoring, care planning andcoordination, bereavement support and training fornon-specialist staff specialist physiotherapists/occupational therapists:provide rehabilitation <strong>of</strong> <strong>patients</strong> <strong>with</strong> disabilityfrom advanced disease and facilitate rapid safedischarge home for <strong>patients</strong>; increasingly importantas advances in treatment alter the natural trajectory<strong>of</strong> incurable diseases specialist social workers: provide advice on financialissues; organise domiciliary/residential social care;provide psychological and bereavement support to<strong>patients</strong> and families, including children.Other team members include specialist pharmacists,dietitians, chaplains, clinical psychologists, counsellors,and creative and complementary therapists.Working <strong>with</strong> other specialtiesClose cooperation between specialists in palliative careand those in other disciplines, especially oncology,surgery, gerontology, cardiology, renal medicine,respiratory medicine, mental health, radiology andorthopaedics, is mandatory. Specialist palliative careteams are small, so it is rarely possible for these teams toprovide comprehensive consultant input to allmultidisciplinary teams (MDTs) in acute hospitals.<strong>Consultant</strong>s in palliative medicine rely on good <strong>working</strong>relationships and communication <strong>with</strong> colleagues inother disciplines.Working <strong>with</strong> GPs and GPs <strong>with</strong> a special interestGPs provide palliative care <strong>with</strong>in the community. Mostcommunity palliative care teams are advisory. Localarrangements vary. In some areas GPs <strong>with</strong> a specialinterest (GPwSIs) have been appointed to facilitatepalliative care training for local GPs. Many specialistpalliative care units employ GPs as specialty doctors orhave trainees drawn from GP specialty training schemes.This helps to develop expertise <strong>with</strong>in primary care andraises the standard <strong>of</strong> primary palliative care locally.Other specialty activity beyond local servicesPalliative medicine consultants provide strategicleadership for palliative and end-<strong>of</strong>-life care <strong>with</strong>in theircancer networks, strategic health authorities and healthboards or trusts, promoting quality and equity <strong>of</strong> accessfor cancer and long-term conditions and developingguidelines, audit and outcome measures.5 Delivering a high-quality serviceWhat is a high-quality service?High-quality specialist palliative care services have thefollowing characteristics: 24-hour access clear referral and discharge criteria based on neednot diagnosis:– ability to receive referrals rapidly and securely, egby fax/email– clear process for clinical screening <strong>of</strong> referrals190 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Palliative medicine– explicit standards for interval between referraland first assessment consultants in palliative medicine providing:– early medical review <strong>with</strong> sufficient time forthorough review and dedicated administrativesupport– rapid links to other relevant disciplines– 24-hour medical advice for colleagues incommunity and hospital MDTs <strong>with</strong> core specialists in palliative medicine,nursing, physiotherapy, occupational therapy andsocial work evidence-based clinical management <strong>with</strong> efficientinformation technology (IT) systems, and access tomedical notes and results <strong>of</strong> investigations efficient and effective communication andcollaborative <strong>working</strong> relationships <strong>with</strong>in core andwider teams clinical audit and research programmes to evaluatetreatments and outcomes education and training programmes for continuingpr<strong>of</strong>essional development (CPD) <strong>of</strong> own staff andothers patient and family involvement in managementplans and discussions about preferred place <strong>of</strong> careand death support for carers and families through illness intobereavement.In addition, specialist inpatient palliative care unitsshould have: adequate number <strong>of</strong> dedicated beds adequate medical staffing at all grades, includingout-<strong>of</strong>-hours cover trained specialist palliative care nurses <strong>with</strong> highnurse:patient ratio (UK average: 1:1.5) appropriate equipment for care <strong>of</strong> weak, cachecticand debilitated <strong>patients</strong> – eg pressure-relievingmattresses, electrically operated beds and chairs,easily operated nurse-call systems and assistedbaths/showers space for private interviews/counselling sessions,prayer, reflection and faith rituals comfortable sitting area for <strong>patients</strong> and visitors,<strong>with</strong> self-catering/overnight facilities dedicated space for viewing the deceased person.Clinical facilities should be integrated whereverpossible. The physical proximity <strong>of</strong> inpatient, outpatientand community teams and day-care facilities promotesgood communication and efficient use <strong>of</strong> consultantexpertiseandtime.Whereaservicecoversawidegeographical area, outlying beds or day-care units maybe provided in community hospitals <strong>with</strong> support fromspecialist palliative care.In acute hospitals, there needs to be private space forconversations, comfortable seating for <strong>patients</strong> andfamilies, self-catering/overnight facilities and near-wardteaching facilities. Drugs should be administered anddispensed promptly to avoid long waits for weak<strong>patients</strong>. Adequate arrangements should be in place forrapid communication <strong>with</strong> the GP and communitynurses when a patient is discharged or dies.A national specialist palliative care peer-reviewedprocess is being tested at present. 9 A quality standardfor end-<strong>of</strong>-life care was published by the NationalInstitute for Health and Care Excellence (NICE) inNovember 2011, consisting <strong>of</strong> 16 quality statementswhich collectively describe a high-quality end-<strong>of</strong>-lifecare service. 10Maintaining and improving the quality <strong>of</strong> careService developments to deliver improved careHigh-quality services need to be responsive to <strong>patients</strong>’needs, efficient in use <strong>of</strong> resources, collaborative inrelationships <strong>with</strong> other services and continuouslyvigilant in maintaining standards <strong>of</strong> care through audit,teaching and research. Service developments include: joint clinics/MDTs in oncology and heart failure,respiratory, renal and neurological medicine access to 24-hour health and social care for palliativecare crises leadership and strategic innovation <strong>with</strong>in localtrusts, including education, evaluation and research implementing end-<strong>of</strong>-life care and advance careplanning tools: integrated care pathways for thedying, Gold Standards Framework and PreferredPriorities for Care, or equivalent workforce planning.Education and trainingWork in this area includes: development <strong>of</strong> consensus syllabus forundergraduate palliative medicine 11 development <strong>of</strong> specialty curriculum, certificateexamination and assessment framework <strong>with</strong> the<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP) development <strong>of</strong> a report on pr<strong>of</strong>essionaldevelopment in end-<strong>of</strong>-life care for <strong>physicians</strong> 12C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 191


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> regular educational events, sometimes incollaboration<strong>with</strong>theRCPorthe<strong>Royal</strong>Society<strong>of</strong>Medicine (RSM) leadership <strong>of</strong> e-learning programme for end-<strong>of</strong>-lifecare (e-ELCA: www.e-elca.org.uk) 13 guidance on clinical governance, outcome measuresand audit mentoring scheme for new consultants training programmes for specialty trainees andspecialty doctorsResearchThere are relatively few academic departments inpalliative medicine. Research in this group <strong>of</strong> vulnerable<strong>patients</strong> <strong>with</strong> a high attrition rate is difficult, yet anevidence base in this clinical area is crucial. Research isrequired in the efficacy and cost-effectiveness <strong>of</strong>palliative care interventions, models <strong>of</strong> care andtranslational research.The APM science committee runs a trainingprogramme in critical appraisal and research methodsfor the specialty. Increasing numbers <strong>of</strong> specialtyregistrars (StRs) and consultants in palliative medicineare achieving higher research degrees. A network <strong>of</strong>APM research champions support new researchersacross UK and Ireland.Specialty tools and national guidelinesNational guidance involving palliative care has appearedin a number <strong>of</strong> influential publications. 14–21 Reports<strong>of</strong> relevance to the specialty include the NationalConfidential Enquiry into Patient Outcome and Death(NCEPOD), 22 the National Audit Office report 23 andGold Standards Framework After Death Analysis. 24 TheNational End <strong>of</strong> Life Care Intelligence Network, launchedin 2010, provides a focus for data relating to end-<strong>of</strong>-lifecare (www.end<strong>of</strong>lifecare-intelligence. org.uk).6 Clinical work <strong>of</strong> consultants<strong>Consultant</strong>s in palliative medicine provide clinicalleadership to specialist palliative care inpatient units,community and hospital palliative care teams, and daycentres. Their role includes: direct clinical care providing advice to primary and secondary carecolleagues attending site-specific cancer MDTs and forlong-term conditions, eg chronic obstructivepulmonary disease (COPD)Table 2 Programmed activities (PAs) contracted andworked (full-time consultants): <strong>Royal</strong> <strong>College</strong> <strong>of</strong>Physicians’ census 2011 25ActivityMean PAscontracted perweekAll activities 10.6 12.1Clinical PAs 7.1 7.6Supporting PAs 2.5 3.4Academic PAs 0.5 0.6Other PAs 0.5 0.5Mean PAs workedper weekPAs contracted and worked (less than full-timeconsultants): <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians’ census2011 25ActivityMean PAscontracted perweekAll activities 7.6 8.6Clinical PAs 5.4 6.0Supporting PAs 1.8 2.1Academic PAs 0.1 0.2Other PAs 0.3 0.3Mean PAs workedper weekNote: most consultants in palliative medicine play a greater role in thestrategic development <strong>of</strong> palliative care services locally than is commonin other specialties. A high percentage <strong>of</strong> (31%) 26 consultants inpalliative medicine work single-handedly, so they carry moreresponsibility for education, audit and research. running joint/parallel clinics <strong>with</strong> other specialists service development.Many are single-handed (31%). 26 Although traineenumbers have increased, palliative medicine remainsconsultant delivered and consultant led. Neither StRsnor consultants usually participate in the on-call rotafor acute general medicine.As outlined in Table 2, full-time consultants work anaverage <strong>of</strong> 48.4 hours (12.1 programmed activities(PAs)) and part-time consultants 34.4 hours (8.6 PAs). 25<strong>Consultant</strong> posts are <strong>of</strong>ten split between local districtgeneral hospitals (DGHs), tertiary hospitals,community services and specialist palliative care units(voluntary/NHS), <strong>with</strong> implications for cross-site<strong>working</strong> and travel. Considerable time is spent liaising<strong>with</strong> GPs and colleagues in primary and secondary care.192 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Palliative medicineA more detailed document on the role <strong>of</strong> the palliativemedicine consultant has been produced by the APM. 27In<strong>patients</strong>There are 223 adult inpatient specialist palliative careservices in the UK (52 beds per million population: 26%funded by the NHS, the rest funded by the voluntarysector). 28 Patients <strong>with</strong> complex needs for symptomcontrol, major emotional distress and family problemsare admitted. The ratio <strong>of</strong> deaths to discharges is 1.22(mean stay 13.7 days). 1 Patients are admitted forterminal care if adequate support/complex needs fordyingathomecannotbemet.Inpatient units may sit in separate buildings in thegrounds <strong>of</strong> acute and community hospitals or asstandalone units. Most have 24-hour, non-resident,specialist medical cover. Some only admit during<strong>working</strong> hours because <strong>of</strong> lack <strong>of</strong> on-site out-<strong>of</strong>-hoursmedical cover. Most units provide 24-hour telephoneadvice for colleagues in the community and hospital.Hospital palliative care teams (346 in the UK 8 )<strong>of</strong>feranadvisory and supportive service <strong>with</strong>out taking overcare from the <strong>patients</strong>’ primary <strong>physicians</strong> and hospitalteams. The service usually runs during daytime <strong>working</strong>hours, <strong>with</strong> some running 7 days a week. Out-<strong>of</strong>-hourstelephone advice is usually accessed from specialistinpatient units.Out<strong>patients</strong>Three hundred specialist outpatient palliative careservices are provided in hospices, community hospitalsor hospitals. 29 Eighty-four per cent <strong>of</strong> new referrals havea primary diagnosis <strong>of</strong> cancer. Some 275 services <strong>of</strong>ferday care, ranging from medical/nursing focused modelsto social or rehabilitative models. 28 Other servicesinclude bereavement support, lymphoedema clinics,creative therapies, counselling and complementarytherapies. See section 7 for community-based care.7 Opportunities for integrated careThe nature <strong>of</strong> palliative care requires integrated team<strong>working</strong> across primary and secondary health and socialcare. Palliative care for <strong>patients</strong> at home is provided byGPs and community nurses, <strong>with</strong> advice, whererequired, from community specialist palliative careteams. There are 291 specialist community teams in theUK. 28 On average, each team sees over 550 new <strong>patients</strong>per year (mean length <strong>of</strong> care: 123 days). 1<strong>Consultant</strong>s in palliative medicine typically <strong>of</strong>fer sharedcare <strong>with</strong> GPs in the community. Support and advicefrom clinical nurse specialists may be supplemented byhands-on care from carers provided by social services orMarie Curie (or equivalent) nurses. In some areas,hospice-at-home services are <strong>of</strong>fered, ranging fromrapid-response services to sustained hands-on care athome, eg the Delivering Choice Programme 30 and otherhybrid versions <strong>of</strong> hospice-at-home and specialistcommunity services. There are now 120hospice-at-home teams. 28 More data and evidenceabout the impact <strong>of</strong> these services will emerge over thenext few years. The Gold Standards Framework (GSF)provides a framework for palliative care provisionin the community by facilitating identification <strong>of</strong><strong>patients</strong> on a GSF register, which triggers discussionabout these <strong>patients</strong>’ end-<strong>of</strong>-life care at regular practicemeetings. 31Education and training is regularly provided byconsultants in palliative medicine as a routine part <strong>of</strong>their work. This helps non-specialist health and socialcare colleagues to remain skilled and up to date inpalliative care. The e-learning programme forend-<strong>of</strong>-life care 13 provides opportunity for blendedlearning across the sectors.8 Workforce requirementsThe RCP’s 2011 census UK 25 identified a head count <strong>of</strong>474 consultants in palliative medicine: England 387,Wales 29, Scotland 42 and Northern Ireland 16. Ofthese, 71% were women, and overall 44.4% workedpart-time. In 2011, there was an 8.4% (10% in 2010)unfilled vacancy rate.Key factors in workforce planning include: ageing population: cancer, predominantly a disease<strong>of</strong> older people, is the commonest diagnosis inpalliative care referrals increasing referrals for non-malignant conditions(20–50% <strong>of</strong> referrals): comparable need in terms <strong>of</strong>symptoms and social and psychological issues asthose <strong>with</strong> cancer high proportion <strong>of</strong> female doctors: 71% <strong>of</strong>consultants and 84% <strong>of</strong> StRs significant proportion <strong>of</strong> less than full-time<strong>working</strong>: 44% <strong>of</strong> consultants and 38% <strong>of</strong> StRs a detailed survey (1997) demonstrated thatworkloads were too high to allow adequate time forC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 193


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 3 <strong>Consultant</strong> workforce requirementMinimum consultant requirement ∗WTEPer 62.2 million population (2011)UK 505England 424Wales 24.8Scotland 42Northern Ireland 14.4† <strong>Consultant</strong>s required per 160,000residents<strong>Consultant</strong>s required per 120,000residents, assuming 30% <strong>of</strong>consultants work less than full time∗ Basedonthefollowingestimates:• 660 cancer deaths per year for population <strong>of</strong> 250,000• 462 referrals per year if 70% access to specialist palliative care• 554 referrals per year if 20% non-cancer referrals are included• 1.54 WTE required if one WTE sees 360 new <strong>patients</strong> per year(APM calculation).† Assuming consultants work full time, one consultant can support apopulation <strong>of</strong> 160,000. However, 30% <strong>of</strong> consultants work less than fulltime, in which case one consultant can support a population <strong>of</strong> 120,000.11Table 4 Work <strong>of</strong> palliative medicine consultantsgenerated by a population <strong>of</strong> 250,000 as PAs(4 hours)Activity Workload PAsDirect clinical careWard rounds 339 admissions/year 4–5Out<strong>patients</strong>4 new <strong>patients</strong>/weekplus 1–6 follow-upsHospital referrals 2–6 <strong>patients</strong>/week 3–5Community referrals4–6 domiciliaryvisits/week22–3Day care Assessments 0.5MDT meetings∗ On-call and weekendward roundsTotal direct patientcareWard: 1/weekCommunity team:1/week2115–19CPD, audit, research and clinical governance, allnecessary for delivering high-quality services. 32Supporting pr<strong>of</strong>essional activities (SPAs)Work to maintain andimprove quality6–8On the basis <strong>of</strong> calculations that include all thesefactors, there should be a minimum <strong>of</strong> one whole-timeequivalent (WTE) consultant in palliative medicine forevery 160,000 residents (1.56 WTE consultants per250,000 population) (see Table 3). Given the excessivehours that consultants currently work, the newconsultant contract (10 PAs/week) and restrictions <strong>of</strong>the European Working Time Directive (EWTD), a moreappropriate pragmatic final estimate would be 2 WTEsper 250,000 population. This would require 505 FTEconsultants across the UK (based on 2011 population <strong>of</strong>62.2 million) comprising for England (424 FTE), Wales(24.8 FTE), Northern Ireland (14.4 FTE) and Scotland(42 FTE). The Centre for Workforce Intelligence reportfor England (2011) based on the RCP 2010 consultantcensus estimated the supply <strong>of</strong> consultants for 2020 willneed to increase to nearly 600 FTE (681 headcount).9 <strong>Consultant</strong> work programme/specimenjob planService models vary. <strong>Consultant</strong> job plans usuallyincorporate more than one <strong>of</strong> the followingTotal 21–27∗ Generally the on-call commitment is onerous. 35 Many consultants arefirst on call for specialist inpatient beds (on-call ratio at least 1:4). Thosewho are single-handed may have second on-call rotas <strong>of</strong> 1:1. Sleep isinfrequently disturbed but workload for first on call during a weekend issignificant. Time <strong>of</strong>f in lieu is rarely included in job plans.components: inpatient hospice, community, acutehospital and day care (see Tables 4 and 5).This job plan does not represent the workload carriedby the majority <strong>of</strong> consultants currently in post andemphasises that the most common current pattern, inwhich a single consultant carries responsibility for workacross all settings, is not sustainable.10 Key points for commissionersThe APM has produced commissioning guidance forspecialist palliative care, in partnership <strong>with</strong> a number<strong>of</strong> other organisations. 33 This can help commissionersto achieve a number <strong>of</strong> wider commissioning goals,especially in relation to domains 2 and 4 <strong>of</strong> the NHSoutcomes framework and the national QIPP indicatorsfor end-<strong>of</strong>-life care. The data and evidence on which194 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Palliative medicineTable 5 <strong>Consultant</strong> work programmeActivity Work PAsDirect clinical careInpatient unitOutpatient clinicsHome/domiciliary visits2 ward rounds (including teaching round)1 MDTCase conferences1–2 clinic sessionsSupervising StR clinicsAdditional urgent referrals as requiredJoint clinics (some)1–2 home visits per weekSupervising StRs and community clinical nurse specialists2.51–20.5–1Day care Assessments 0.5Acute hospital team 2 ward assessments (including teaching round) 2.5MDT meeting <strong>with</strong> ward and community 1On call for specialist advice and emergenciesOn-call weekend ward rounds1–2Supporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve quality <strong>of</strong>careOther NHS responsibilitiesExternal dutiesEducation, training, appraisal, management, servicedevelopment, audit, clinical governance, CPD andrevalidation, researcheg medical director, clinical director, lead clinician,clinical tutoreg work for deanery, royal colleges, specialist society,DH, other bodies2.5By local agreement<strong>with</strong> trustBy local agreement<strong>with</strong> trustthis guidance has been produced will need to beupdated in the coming years, and the commissioningadvice revised to take into account the additionalpressure from ageing and long-term conditions inparticular. Generic guidance for commissioningend-<strong>of</strong>-lifecareisalsoavailable. 341 Over the next 30 years, the demand for palliativecare services will continue to increase because<strong>of</strong> an ageing population and a predicted 20%increase in mortality rates (<strong>patients</strong> aged 80 yearsor more).2 Equitable service delivery is needed for long-termconditions, as well as cancer, based on joint healthand social care needs assessments.3 Strategic planning requires collaboration <strong>of</strong>statutory health, social care and voluntary sectorproviders, <strong>with</strong> involvement <strong>of</strong> public, <strong>patients</strong> andusers in all aspects <strong>of</strong> the commissioning cycle.4 GPs and specialists need to be fully involved inplanning and commissioning palliative careservices and developing care pathways which:a identify key triggers/criteria for the end-<strong>of</strong>-lifecare phase for cancer and long-term conditionsb promote patient choice and advance careplanningc are based on national guidance and useoutcome measures.5 Integrated multipr<strong>of</strong>essional health and social careteams are necessary to provide high-qualitycoordinated care to <strong>patients</strong> and their families.6 Service specifications need to provide the range andtype <strong>of</strong> services for optimal delivery across hospital,community, care home or hospice and otherlocations, eg prisons and hostels for the homeless.7 Seven-day and 24-hour generic and specialistpalliative care services are critical to enable <strong>patients</strong>to remain in the community by meetingC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 195


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>out-<strong>of</strong>-hours palliative care crises and avoidingcarer breakdown.8 Palliative medicine consultants provide clinicalleadership, promote care coordination acrosshospital, hospice and community, reduce symptomburden experienced by <strong>patients</strong>, facilitate successfulearlier discharges into the community and preventinappropriate admissions. 279 A skilled health and social care workforce will be amajor cost driver for improving end-<strong>of</strong>-life care inall care settings and is a fundamental part <strong>of</strong> thework <strong>of</strong> palliative care <strong>physicians</strong> andpr<strong>of</strong>essionals.10 Outcome measures should be embedded <strong>with</strong>incontracts and funding mechanisms for quality caredelivered in all settings. In this patient population,outcomes can be difficult to measure but should bebased on the End <strong>of</strong> Life Care Quality Markers(2009) 21 and NICE Quality Standards for End <strong>of</strong>Life Care. 10References1 National Council for Palliative Care. National survey <strong>of</strong>patient activity data for specialist palliative care services:MDS full report for the year 2010–11. London: NCPC,2012. www.ncpc.org.uk/publication/mds-full-reportyear-2009-2010-0[Accessed 19 Jan 2013].2 National Council for Palliative Care. National survey <strong>of</strong>patient activity data for specialist palliative care services:MDS full report for the year 2006–2007. London: NCPC,2007.3 National Council for Palliative Care. National survey <strong>of</strong>patient activity data for specialist palliative care services:MDS full report for the year 2007–2008. London:NCPC,2008.4 Department <strong>of</strong> Health. End<strong>of</strong>lifecarestrategy:promotinghigh quality care for all adults at the end <strong>of</strong> life.London:DH, 2008.5 Scottish Government. Living and dying well: a nationalaction plan for palliative and end <strong>of</strong> life care in Scotland.Edinburgh: Scottish Government, 2008.6 Department <strong>of</strong> Health, Social Services and Public Safety.Living matters: dying matters. A palliative and end <strong>of</strong> lifecare strategy for adults in Northern Ireland. Belfast:DHSSPS, 2010.7 All Wales Palliative Care Planning Group. Palliative careplanning group Wales: report to the Minister for Healthand Social Services. Wales: AWPCPG, 2008.http://wales.pallcare.info [Accessed 19 January 2013].8 National End <strong>of</strong> Life Care Programme. Newsletter, June2010. www.endo&#64258;ifecareforadults.nhs.uk[Accessed 19 January 2013].9 National Cancer Action Team. National Cancer PeerReview Programme: manual for cancer services: specialistpalliative care measures. London: National Cancer ActionTeam, 2012.10 National Institute for Health and Care Excellence.Quality standard for end <strong>of</strong> life care for adults. London:NICE, 2011. http://guidance.nice.org.uk/QS13 [Accessed19 January 2013].11 Paes P, Wee B. A Delphi study to develop the Associationfor Palliative Medicine consensus syllabus forundergraduate palliative medicine in Great Britain andIreland. Palliat Med 2008;22:360–4.12 Joint <strong>working</strong> party <strong>of</strong> <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians <strong>of</strong>London, the National End <strong>of</strong> Life Care Programme andthe Association for Palliative Medicine <strong>of</strong> Great Britainand Ireland. Improving end-<strong>of</strong>-life care: pr<strong>of</strong>essionaldevelopment for <strong>physicians</strong>. London: RCP, 2012.13 Department <strong>of</strong> Health, Association for PalliativeMedicine <strong>of</strong> Great Britain and Ireland, National End <strong>of</strong>Life Care Programme and e-Learning for Healthcare.E-learning for end <strong>of</strong> life care for all. London:DH,APM,NEoLCP and e-Learning for Healthcare, 2010.www.e-elca.org.uk [Accessed 19 January 2013].14 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Palliative care services:meeting the needs <strong>of</strong> <strong>patients</strong>. London: RCP, 2007.15 National Institute for Health and Care Excellence.Guidance on cancer services: improving supportive andpalliative care for adults <strong>with</strong> cancer. The manual.London: NICE, 2004.16 Department <strong>of</strong> Health. The national service frameworkfor renal services. Part two: chronic kidney disease,acute renal failure and end <strong>of</strong> life care.London:DH,2006.17 Department <strong>of</strong> Health. National service framework forolder people. London: DH, 2001.18 National Institute for Health and Care Excellence.Dementia: supporting people <strong>with</strong> dementia andtheir carers in health and social care. London: NICE,2006.19 Department <strong>of</strong> Health. Coronary heart disease: nationalservice framework for coronary heart disease – modernstandards and service models. London: DH, 2000.20 Department <strong>of</strong> Health. End<strong>of</strong>lifecarestrategy: promotinghigh quality care for all adults at the end <strong>of</strong> life.London:DH, 2008.21 Department <strong>of</strong> Health. End <strong>of</strong> life care strategy: qualitymarkers and measures for end <strong>of</strong> life care.London:DH,2009.22 National Confidential Enquiry into Patient Outcome andDeath. Caring to the end? A review <strong>of</strong> the care <strong>of</strong> <strong>patients</strong>who died in hospital <strong>with</strong>in four days <strong>of</strong> admission.London: NCEPOD 2009.23 National Audit Office. End <strong>of</strong> life care.London:NAO,2008.196 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Palliative medicine24 Gold Standards Framework (audit tool). www.goldstandardsframework.org.uk/GSFAuditTool.html[Accessed 19 January 2013].25 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK.Census <strong>of</strong> consultant <strong>physicians</strong> and medical registrars inthe United Kingdom, 2011: data and commentary.London: RCP, 2013.26 Association for Palliative Medicine <strong>of</strong> Great Britain andIreland. Reports from medical workforce database(2005–6). Southampton: APM, 2006.27 The Association for Palliative Medicine <strong>of</strong> Great Britainand Ireland. The role <strong>of</strong> the palliative medicine consultant.Southampton: APM, 2012.28 Help the Hospices. The UK hospice and palliative caredirectory 2012–13. London: Help the Hospices, 2012.29 National Council for Palliative Care. National survey <strong>of</strong>patient activity data for specialist palliative care services:MDS full report for the year 2008–2009. London: NCPC,2010.30 Addicott R, Dewar S. Improving choice at end <strong>of</strong> life: adescriptive analysis <strong>of</strong> the impact and costs <strong>of</strong> the MarieCurie Delivering Choice Programme in Lincolnshire.London: King’s Fund, 2008.31 Gold Standards Framework.www.goldstandardsframework.org.uk [Accessed 19January 2013].32 Makin W, Finlay IG, Amesbury B, Naysmith A, Tate T.What do palliative medicine consultants do? Palliat Med2000;14:405–9.33 Association for Palliative Medicine <strong>of</strong> Great Britain andIreland, <strong>Consultant</strong> Nurse in Palliative Care ReferenceGroup, Marie Curie Cancer Care, National Council forPalliative Care, and the Palliative Care Section <strong>of</strong> the<strong>Royal</strong> Society <strong>of</strong> Medicine. Commissioning guidance forspecialist palliative care: helping to deliver commissioningobjectives. London, 2012.34 National Institute for Health and Care Excellence. NICEcommissioning guidance for end <strong>of</strong> life care.London:NICE, 2011.www.nice.org.uk/usingguidance/commissioningguides/end<strong>of</strong>lifecare/end<strong>of</strong>lifecareadults.jsp [Accessed 19January 2013]35 Tebbit P. Population-based needs assessment for palliativecare. A manual for cancer networks. London: NationalCouncil for Hospice and Specialist Palliative CareServices, 2004: p 34.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 197


2 Specialties Pharmaceutical medicinePharmaceutical medicineBen Cottam Policy and communications coordinator, Faculty <strong>of</strong> PharmaceuticalMedicine, London1 Description <strong>of</strong> the specialtyPharmaceutical medicine is a medical specialtyconcerned <strong>with</strong> the discovery and development,evaluation, licensing and monitoring <strong>of</strong> medicinalproducts, for the benefit <strong>of</strong> <strong>patients</strong> and public health.Pharmaceutical <strong>physicians</strong> work in the pharmaceuticalindustry, drug regulatory authorities, contract researchorganisations and academia. They have a close affinity<strong>with</strong> their medical colleagues in primary and secondaryhealthcare.Pharmaceutical medicine is based on the knowledgeand understanding <strong>of</strong> how medicines work, thelimitations and variability <strong>of</strong> response to treatments,and how therapies can be used optimally in clinicalpractice. In addition to expertise in basic research,medicines development and evaluation, clinical trialsand registration, pharmaceutical <strong>physicians</strong> also need agood understanding <strong>of</strong> pharmacoeconomics, medicalaspects <strong>of</strong> the marketing <strong>of</strong> medicines, businessadministration and the social impact <strong>of</strong> healthcare on<strong>patients</strong> and public health.The roles <strong>of</strong> pharmaceutical <strong>physicians</strong>Some pharmaceutical <strong>physicians</strong> are involved indefining the biological mechanisms <strong>of</strong> disease, enablingmedicines to be identified that specifically target theillness. However, the majority <strong>of</strong> doctors in the specialtyare responsible for the design, management andimplementation <strong>of</strong> clinical trials and work <strong>with</strong> a team<strong>of</strong> clinical investigators and supporting clinical staff.Theyareeitherdirectlyemployedbyindustry,orworkas independent consultants. Their work contributes toall stages <strong>of</strong> clinical trials as described below: A small number <strong>of</strong> pharmaceutical <strong>physicians</strong> areinvolved in phase 1 trials, which are conducted indedicated clinical pharmacology units and involvethefirstdosing<strong>of</strong>adrugto(usuallyhealthy)humans for safety and tolerability testing,measurement <strong>of</strong> pharmacological effects andpharmacokinetic pr<strong>of</strong>iling. Depending upon thetreatment indication and the type <strong>of</strong> drug beingevaluated, phase I studies may also be performed in<strong>patients</strong>, eg in oncology studies. A larger number <strong>of</strong> <strong>physicians</strong> are involved in phase2 and 3 trials. Phase 2 trials are generally the firstconducted in <strong>patients</strong> and are small-scale trials thatgive an indication that the drug works effectivelyand safely. Pharmaceutical <strong>physicians</strong> choosesuitable disease targets, and design trials usingappropriate measures <strong>of</strong> clinical efficacy,pharmacodynamic endpoints and safety. Phase 3 trials are <strong>of</strong> larger scale, involving hundredsor thousands <strong>of</strong> <strong>patients</strong> and are required to provethe clinical efficacy and safety <strong>of</strong> a drug. Due to thepatient numbers required and the internationalnature <strong>of</strong> many pharmaceutical companies, phase 3trials are <strong>of</strong>ten carried out globally, requiringpharmaceutical <strong>physicians</strong> to adapt their practicesignificantly depending on location andcircumstance. Pharmaceutical <strong>physicians</strong> also consult on theimplementation <strong>of</strong> phase 4 clinical studies. Once amarketing authorisation for a new medicine isgranted and the drug opened to a wider patientgroup, post-marketing and continued safeprescribing needs to be closely monitored. Clinicaldoctors and pharmacists work closely <strong>with</strong> thepharmaceutical <strong>physicians</strong> responsible for drugsafety to ensure full, timely and complete analysis <strong>of</strong>unexpected adverse drug reactions alongside theregulatory agencies, to comply <strong>with</strong> their necessaryreporting regulations.All trials are strictly governed by regulations designed toprotect the safety <strong>of</strong> <strong>patients</strong>. Many pharmaceutical<strong>physicians</strong> work <strong>with</strong>in the regulatory agencies, such asthe Medicines and Healthcare products RegulatoryAgency (MHRA) and the European Medicines Agency(EMA), to ensure that trials are being carried out to thehighest ethical and safety standards and in the bestinterests <strong>of</strong> the patient. 1,2Some <strong>physicians</strong> are involved in medical affairs, whichincludes the marketing <strong>of</strong> medicinal products. Thesedoctors conduct market support studies, provideC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 199


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>medical input to marketing strategy, support sales staffin the field, review drug advertising and the safety(pharmacovigilance) <strong>of</strong> marketed drugs, and ensurethat the information materials for both prescribers and<strong>patients</strong> are as accurate and easy to understand aspossible.Pharmaceutical <strong>physicians</strong> and <strong>patients</strong>As mentioned previously, those participating in clinicaltrials are usually either <strong>patients</strong> suffering <strong>with</strong> theparticular condition under investigation, or can behealthy members <strong>of</strong> the public who volunteer (and canreceive remuneration) to take part in trials. However,apart from phase 1 clinical trials, direct patient contactis rare for pharmaceutical <strong>physicians</strong>. Phase 1 trials arecarried out in independent ‘clinical research units’ andhere the pharmaceutical <strong>physicians</strong> have medicalresponsibility for the safety <strong>of</strong> the participants and musthave up-to-date knowledge <strong>of</strong> resuscitation techniquesand treatment <strong>of</strong> medical emergencies. These <strong>physicians</strong>regularly conduct physical examinations for fitness, takeblood, give injections etc. Phase 2 and 3 trials areusually carried out <strong>with</strong> <strong>patients</strong> ‘in-the-field’ andpharmaceutical <strong>physicians</strong> are more involved inmonitoring the overall safety <strong>of</strong> <strong>patients</strong>, rather thanday-to-day contact. All clinical trials require theinformed consent <strong>of</strong> the participants andpharmaceutical <strong>physicians</strong> will be involved indeveloping the requisite consent forms. Pharmaceutical<strong>physicians</strong> who work for regulatory agencies havealmost no direct patient contact.Despite the fact that pharmaceutical doctors have verylittle direct patient contact compared <strong>with</strong> typicalhospital doctors or GPs, the medicines and vaccines thatthey develop can ultimately affect the lives <strong>of</strong> millions <strong>of</strong>people across the world. Thus, <strong>working</strong> for the benefit<strong>of</strong> the public is still very much at the heart <strong>of</strong> apharmaceutical physician’s endeavours. Despite this,relations between the pharmaceutical industry, the NHSand <strong>patients</strong> are <strong>of</strong>ten strained. The report in 2009 bythe <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP) Innovating forhealth: <strong>patients</strong>, <strong>physicians</strong>, the pharmaceutical industryand the NHS 3 suggested that many <strong>patients</strong> remainconcerned that they do not enjoy equal access tomedicines, nor do they believe that the full range <strong>of</strong>innovative medicines that are available is brought totheir attention, thus undermining their confidence inthe entire prescribing process. The report also indicatedthat <strong>patients</strong> in the UK are usually very willing toparticipate in clinical trials but that <strong>patients</strong> report alack <strong>of</strong> opportunity. The <strong>working</strong> party that producedthis report is now coordinating the activities that willaddress these issues.Areas <strong>of</strong> workPharmaceutical <strong>physicians</strong> are involved in studiesconcerned <strong>with</strong> the research and development <strong>of</strong> newmedicines in almost all disease areas and will havespecialist knowledge in their chosen field <strong>of</strong> research.There are globally about 5,000 medicines and about350 vaccines currently in development (although only asmall percentage <strong>of</strong> these will successfully make it tomarket), <strong>with</strong> the majority <strong>of</strong> research efforts beingdirected towards new treatments for cancers, heartdisease and stroke, diseases <strong>of</strong> the central nervoussystem and tackling the burden <strong>of</strong> infection indeveloping countries (source: CMR International).2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralAs the majority <strong>of</strong> pharmaceutical <strong>physicians</strong> workoutside the NHS and in such a wide variety <strong>of</strong> roles it isimpossible to crystallise how the service that theyprovide is organised. Pharmaceutical <strong>physicians</strong> are tobe found at all levels <strong>of</strong> service in commercial, academicand government institutions.Pharmaceutical <strong>physicians</strong> do not operate in thestandard referral channels <strong>of</strong> GPs and hospital doctors.Although they are involved in designing the protocol forpatient selection etc, they are not involved in individualpatient referral to a site conducting a clinical trial.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareAs mentioned previously, very few pharmaceutical<strong>physicians</strong> have direct contact <strong>with</strong> <strong>patients</strong>, thoughtheir work is always for the benefits <strong>of</strong> <strong>patients</strong> and thepublic.Although the pharmaceutical physician does not deliverthe information regarding trials directly to the patient,they are involved in coordinating all the relevantinformation concerning the patient’s participation;including why the trial is being carried out, why thispatient is involved, and what the potential or expectedbenefits and risks are. One <strong>of</strong> the main sources <strong>of</strong>information for clinical trials <strong>patients</strong> is the NHSwebsite ‘Involve’ 4 which is managed by the National200 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Pharmaceutical medicineInstitute for Health Research (NIHR). Many <strong>of</strong> thedisease-specific charities also provide advice andinformation for <strong>patients</strong> who are already undergoingor thinking about becoming involved in clinicaltrials.The issue <strong>of</strong> post-trial patient information is consideredto be an integral part <strong>of</strong> patient rights and has beenmentioned as part <strong>of</strong> the World Medical Association’sDeclaration <strong>of</strong> Helsinki on the Ethical Principles forMedical Research Involving Human Subjects, 5 whereparagraph 33 states:At the conclusion <strong>of</strong> the study, <strong>patients</strong> entered intothe study are entitled to be informed about the outcome<strong>of</strong> the study and to share any benefits that resultfrom it.Despite this, <strong>patients</strong> are still not routinely kept up todate <strong>with</strong> the outcomes <strong>of</strong> trials that they have beeninvolved in. The main reason for this is that <strong>of</strong>ten manymonths or years have elapsed before the analysis <strong>of</strong> atrial is complete and the communication channelsbetween the investigators and <strong>patients</strong> and theirconsultants have <strong>of</strong>ten broken down. Clinical trialparticipants are coded and thus the responsiblepharmaceutical physician does not have access toindividual <strong>patients</strong>. At the end <strong>of</strong> the trial, the outcomesare reported to the investigators involved and it is theirresponsibility to pass this information on to theparticipants from their centre.4 Interspecialty and interdisciplinaryliaisonAlthough their contact is <strong>of</strong>ten limited, pharmaceutical<strong>physicians</strong> work <strong>with</strong> clinicians across almost the entirespectrum <strong>of</strong> medicine. They are available to talk toclinicians <strong>working</strong> in a particular field and to discuss theuse <strong>of</strong> medicines in a particular condition. Clinicaldoctors always have a route <strong>of</strong> contact <strong>with</strong> a company’smedical information department when issues aroundmedicinal products arise, and these circumstances arelikely to involve a pharmaceutical physician.Increasingly, pharmaceutical <strong>physicians</strong> are also actingas direct sources <strong>of</strong> expert information on the medicinesthat their companies provide to doctors <strong>working</strong> in theNHS. This interaction is usually initiated by theconsulting clinician and can act to greatly enhancepatient care but is currently an underusedrelationship.5 Delivering a high-quality serviceWhat is a high-quality service?Due to the diverse nature <strong>of</strong> their roles, it is difficulthere to define precisely what constitutes a high-qualityservice as delivered by pharmaceutical <strong>physicians</strong>.Beyond phase 1, the running <strong>of</strong> a safe and efficientclinical trial requires close collaboration <strong>of</strong> the trialsponsor, the hospital or clinic where the <strong>patients</strong> arelocated and the consultant or GP responsible for them,the chief investigator and other healthcare pr<strong>of</strong>essionalssupporting the research and the ethics committeeresponsible.To ensure a safe, rigorous and well-executed trial thesponsor or chief investigator must go through severalauthorisation procedures before, during or after aclinical trial:1 The sponsor or investigators must first apply to theMHRA for clinical trial authorisation (CTA). Theythen usually register the trial for an internationalstandard randomised controlled trials number(ISRCTN) and although this is not compulsory itensures that the trial complies <strong>with</strong> the requirements<strong>of</strong> the International Committee <strong>of</strong> Medical JournalEditors (ICMJE) – a prerequisite for publishing trialdata in most journals.2 Ethical approval for the trial must be sought by theprincipal investigator through a research ethicscommittee (REC), part <strong>of</strong> the National ResearchEthics Service (NRES).3 Once a trial is under way, safety and progressreporting must be carried out to the appropriateREC both on a periodic basis (both 6-monthlyand annually) and also whenever there is anunexpected or dangerous event, known as asuspected unexpected serious adverse reaction(SUSAR).4 When a trial is finished it must be reported to theMHRA and the relevant REC (<strong>with</strong>in 90 days <strong>of</strong> itsconclusion or <strong>with</strong>in 15 days <strong>of</strong> early termination)and a summary <strong>of</strong> the final report on the researchshould be sent to the main REC <strong>with</strong>in 12 months <strong>of</strong>the end <strong>of</strong> the project.Those pharmaceutical <strong>physicians</strong> who work for theregulatory agencies have a very different remit andtherefore different definitions <strong>of</strong> a quality service.Their prime responsibility is to protect publichealth.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 201


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Maintaining and improving the quality <strong>of</strong> carePharmaceutical <strong>physicians</strong> are predominantly employedby private companies which will have their own strictcodes <strong>of</strong> conduct, ethical principles and protocols forensuring the ongoing high quality <strong>of</strong> work carried outunder their sponsorship. These practices are furthersupported by pr<strong>of</strong>essional codes <strong>of</strong> practice 6 andstatutes that enshrine good clinical practice (GCP) andthe safety and well-being <strong>of</strong> the patient and/or researchsubject.The majority <strong>of</strong> pharmaceutical <strong>physicians</strong> in the UKare members <strong>of</strong> the Faculty <strong>of</strong> Pharmaceutical Medicine(FPM), a Faculty <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong>the UK. The FPM conducts pharmaceutical medicinespecialty training (PMST) which enables qualifieddoctors to obtain specialist registration inpharmaceutical medicine <strong>with</strong> the General MedicalCouncil (GMC). The overall aim <strong>of</strong> PMST is to produceaccredited pharmaceutical <strong>physicians</strong>, who areequipped <strong>with</strong> specialist knowledge and comprehensiveskills and competencies to practise to the highest ethicaland pr<strong>of</strong>essional standards, for the benefit and safety <strong>of</strong><strong>patients</strong> and the public, in the development andmaintenance <strong>of</strong> medicines. The earliest entry point intoPMST is at ST3 level.The FPM also coordinates the continuing pr<strong>of</strong>essionaldevelopment (CPD) <strong>of</strong> its members, though it does notcurrently provide modules for CPD accreditation. TheFPM is currently developing the framework for therevalidation <strong>of</strong> pharmaceutical <strong>physicians</strong> andrecommends that all practising pharmaceutical<strong>physicians</strong> registered <strong>with</strong> the GMC should have aLicence to Practise and therefore make themselvesavailable for revalidation. Because <strong>of</strong> the diverse nature<strong>of</strong> pharmaceutical <strong>physicians</strong>’ roles, coupled <strong>with</strong> thefact that they work outside the NHS and that themajority <strong>of</strong> their work does not involve direct patientcontact, their revalidation process is going to be verydifferent to the majority <strong>of</strong> doctors. It is vitallyimportant that the revalidation <strong>of</strong> pharmaceutical<strong>physicians</strong> is carried out in a manner that is as objective,transparent and robust as possible. The FPM willcontinue to develop guidance on revalidation and towork closely <strong>with</strong> the GMC.6 Clinical work <strong>of</strong> consultantsApart from the few pharmaceutical <strong>physicians</strong> whocontinue to work part time in a wide variety <strong>of</strong> otherspecialties and general practice, the pr<strong>of</strong>ession is notengaged in clinical work.7 Opportunities for integrated careThis does not directly apply to pharmaceutical<strong>physicians</strong>, but contact between nurse and pharmacistprescribers and pharmaceutical <strong>physicians</strong> will occurwhere the healthcare pr<strong>of</strong>essional is seeking informationor advice from the sponsor <strong>of</strong> the product.8 Workforce requirements for the specialtyThe FPM has over 1,100 UK-based members, but hasestimated that there are over 1,500 pharmaceutical<strong>physicians</strong> currently practising in the UK. It is difficultto give a more precise figure for this, again due to thediverse and extra-NHS nature <strong>of</strong> the pr<strong>of</strong>ession.As <strong>of</strong> October 2012 there were 177 trainees inpharmaceutical medicine <strong>with</strong> a national trainingnumber undertaking training in 60 approvedorganisations. A total <strong>of</strong> 193 <strong>physicians</strong> have nowcompleted specialty training in pharmaceuticalmedicine and can be awarded the Certificate <strong>of</strong>Completion <strong>of</strong> Training (CCT) <strong>with</strong> eligibility forSpecialist Registration <strong>with</strong> the GMC; two <strong>physicians</strong>have also completed training through the Certificate <strong>of</strong>Eligibility for Specialist Registration CombinedProgramme (CESR-CP) route. There are 34 seniorspecialty advisers whose role is one <strong>of</strong> governance andquality management <strong>of</strong> the training programmes <strong>with</strong>intheir allocated sites. There are 92 trained and approvededucational supervisors (ESs) and associate educationalsupervisors (AESs) who are actively supervisingtrainees.The revised PMST curriculum, launched in August2010, is now established for newly enrolling trainees.Trainees following PMST2, as it is known, undertakeworkplace-based assessments (WPBA) and use ane-portfolio to collect evidence <strong>of</strong> competency andsupporting information to record their trainingprogression.9 <strong>Consultant</strong> work programme/specimenjob planPharmaceutical <strong>physicians</strong> can be self-employed, workfor a multinational pharmaceuticals company or a202 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Pharmaceutical medicineregulatory agency or in academia. Their work involvesdeveloping medicines and vaccines in almost all diseaseareas, both at home and abroad. Because <strong>of</strong> this hugediversity it is almost meaningless to produce a ‘typical’work programme or job plan for a pharmaceuticalphysician.10 Key points for commissioners1 The specialty <strong>of</strong> pharmaceutical medicine currentlyhas the eleventh highest number <strong>of</strong> trainees.2 Pharmaceutical <strong>physicians</strong> work in a very diversespecialty, researching and developing medicines inalmost all disease areas.3 Although few pharmaceutical <strong>physicians</strong> workdirectly <strong>with</strong> <strong>patients</strong> they consider their work to befor the benefit <strong>of</strong> public health first and foremost.4 Some pharmaceutical <strong>physicians</strong> are employed inthe public sector, but most are employed privatelyin companies ranging from small consultancies tomultinational companies <strong>with</strong> billions <strong>of</strong> pounds<strong>of</strong> annual turnover.5 Pharmaceutical <strong>physicians</strong> are the providers <strong>of</strong>information and data to <strong>patients</strong> undergoing trials,via the investigator.6 Pharmaceutical <strong>physicians</strong> almost always work inmultidisciplinary teams, <strong>with</strong> doctors <strong>of</strong> allspecialties, trials investigators and supportiveclinical staff.7 Pharmaceutical medicine is a global specialtyand therefore many pharmaceutical <strong>physicians</strong>who have qualified in the UK now workoverseas.8 Pharmaceutical medicine is a very broad-basedspecialty and therefore welcomes doctors from abroad spectrum <strong>of</strong> specialties including surgeryand paediatrics.9 Pharmaceutical <strong>physicians</strong> are able to pursue avariety <strong>of</strong> specialties in their careers and are likelyto build a diverse portfolio.10 Virtually all medicines available for prescriptionwill have had considerable input frompharmaceutical <strong>physicians</strong> in their development.References1 EuropeanUnion. EU clinical trials directive 2001/20/EC,2001.2 UKGovernment. Medicines for human use (clinical trials)regulations (SI 2004/1031), 2004.3 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Innovating for health:<strong>patients</strong>, <strong>physicians</strong>, the pharmaceutical industryand the NHS.Report<strong>of</strong>a<strong>working</strong>party.London:RCP, 2009.4 The NHS ‘involve’ website. www.invo.org.uk5 WMA Declaration <strong>of</strong> Helsinki. Ethical principles formedical research involving human subjects. Adoptedbythe 18th WMA General Assembly, Helsinki, Finland,June 1964. Most recently amended by the 59th WMAGeneral Assembly, Seoul, October 2008.6 Association <strong>of</strong> the British Pharmaceutical Industry. ABPICode <strong>of</strong> Practice for the Pharmaceutical Industry 2008(and references therein).C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 203


2 Specialties Rehabilitation medicineRehabilitation medicineDr John P McCann MD FRCP FRCPI <strong>Consultant</strong> in rehabilitation medicineDr Christopher W Roy MBChB FRCP(Glasg) Retired consultant rehabilitation medicinePr<strong>of</strong>essor Christopher D Ward MD FRCP Retired pr<strong>of</strong>essor <strong>of</strong> rehabilitation medicine1 Description <strong>of</strong> the specialty<strong>Consultant</strong>s in rehabilitation medicine (RM) servepeople <strong>with</strong> complex disabilities arising from conditionssuch as spinal and head injuries, stroke, multiplesclerosis (MS), musculoskeletal disorders, congenital oracquired limb loss, muscle disorders, cerebral palsy andspina bifida. Roles include: confirming diagnoses and prognoses preventing and treating symptoms andcomplications contributing to life decisions providing information, support and counselling for<strong>patients</strong>, families and carers.Most RM consultants lead and coordinate amultidisciplinary team (MDT). Although the specialtywas originally developed for disabled people <strong>of</strong> <strong>working</strong>age, 1,2 RM is now relevant to people <strong>of</strong> all ages.The World Health Organization’s (WHO) Internationalclassification <strong>of</strong> functioning, disability and health 3provides a conceptual framework. This recognises thesocial and physical environment as a target forinterventions: for example, someone complaining <strong>of</strong>spinal pain may benefit from different seatingarrangements, drugs or medical treatments. The clinicalskills <strong>of</strong> RM specialists are essential for the effective use<strong>of</strong> many assistive technologies.Rehabilitation programmes are important in acute andnon-acute conditions. For example, RM consultantshelp individuals <strong>with</strong> MS to manage their own disabilityand prevent secondary complications, while providingtreatment as required.The British Society <strong>of</strong> Rehabilitation Medicine (BSRM)(www.bsrm.co.uk) provides further information on thespecialty.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralRehabilitation medicine is a consultant-led service thatworks closely <strong>with</strong> MDTs. <strong>Consultant</strong>s haveresponsibility for in<strong>patients</strong> in neurologicalrehabilitation units but also consult in stroke units,other wards (including pre-amputation) andmultidisciplinary outpatient services. Rehabilitation <strong>of</strong>people <strong>with</strong> spinal cord injuries occurs throughsupra-regional centres. Specialist neurologicalrehabilitation centres accept the most complex <strong>patients</strong>.Rehabilitation medicine has important relationships<strong>with</strong> trauma, orthopaedics, neurology, neurosurgery,vascular surgery, acute medicine and palliativemedicine. 4 RM has a central role in the early andongoing management <strong>of</strong> <strong>patients</strong> <strong>with</strong>in the majortrauma networks.Many consultants work in the community. In England,recent drivers for such services include the Nationalservice framework (NSF) for long-term conditions 5 andthe Department <strong>of</strong> Health’s Transforming communityservices programme 6 and Liberating the NHS whitepaper. 7 Community work entails frequent interactions<strong>with</strong> primary care, psychiatry, urology, palliativemedicine and many other services. Most RMconsultants carry out home visits or review people innursing homes.Referrals come from GPs or consultant colleagues.In addition, pr<strong>of</strong>essions allied to medicine triggerreferrals.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcarePatient-centred care is central to RM, which involvesmeetings <strong>with</strong> disabled individuals, family membersC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 205


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>and others. The ability to facilitate these meetings is animportant consultant skill. Communications betweenpr<strong>of</strong>essionals and <strong>patients</strong> are highly developed andinclude evaluations <strong>of</strong> rehabilitation goals. <strong>Consultant</strong>sin RM use educational approaches to help <strong>patients</strong> andfamilies, <strong>of</strong>ten raising their expectations <strong>of</strong> potentialachievement, and to support self-management. Patientsupport groups can be a major help in rehabilitation.<strong>Consultant</strong>s in RM typically have close relationships<strong>with</strong> local groups, and many work <strong>with</strong> national patientor carer-led organisations.Rehabilitation must always consider other peopleimportant to the patient. The separate needs <strong>of</strong> carersmust be appreciated, but balancing the interests <strong>of</strong> theindividual patient <strong>with</strong> those <strong>of</strong> others can pose ethicalchallenges when the disabled individual has reducedcapacity. An important challenge for RM consultants isto understand the needs <strong>of</strong> people from differentreligious, cultural and ethnic backgrounds. RMfacilitates innovative approaches, <strong>with</strong> a great deal <strong>of</strong>expertise on cultural differences <strong>with</strong>in the specialty;however, the cultural responsiveness <strong>of</strong> rehabilitationservices needs further development.4 Interspecialty and interdisciplinaryliaisonMost aspects <strong>of</strong> RM require an MDT. Evidence for ateam approach comes from research on acquired braininjury and MS. 8,9 The key to MDT <strong>working</strong> is thatpr<strong>of</strong>essional roles are flexible, <strong>with</strong> the needs <strong>of</strong> adisabled individual superseding disciplinaryboundaries. Interspecialty links are strong throughoutrehabilitation, and links <strong>with</strong> primary care andcommunity services are particularly important duringcommunity reintegration. Social services work closely<strong>with</strong> RM teams, alongside education, employment,housing and legal services, and voluntary agencies.Neurology and neurosurgery interact closely <strong>with</strong> RM inmanaging long-term neurological conditions. Vascularsurgery interacts specifically <strong>with</strong> RM for amputations.RM works closely <strong>with</strong> orthopaedics and neurosurgeryin the management <strong>of</strong> <strong>patients</strong> following severe trauma.Other joint work <strong>with</strong> RM consultants includes: managing handover <strong>of</strong> young disabled people frompaediatrics to RM managing spasticity in collaboration <strong>with</strong>geriatricians <strong>working</strong> <strong>with</strong> surgeons to plan procedures andpostoperative rehabilitation following spinal or jointsurgery and tenotomies sharing care <strong>with</strong> gastroenterologists duringinsertion <strong>of</strong> feeding tubes obtaining support from otorhinolaryngologists inthe management <strong>of</strong> tracheotomy <strong>working</strong> <strong>with</strong> anaesthetists in the management <strong>of</strong>complex pain collaborating <strong>with</strong> psychiatrists for <strong>patients</strong> <strong>with</strong>neurological conditions, including traumatic braininjury, functional disorders and Huntington’sdisease <strong>working</strong> <strong>with</strong> urologists in the management <strong>of</strong>continence <strong>working</strong> <strong>with</strong> palliative medicine consultants in themanagement <strong>of</strong> people <strong>with</strong> rapidly progressiveneurological conditions (eg motor neurondisease).In the community, RM makes rehabilitation expertiseaccessible to disabled people and provides an interfacefor specialist community pr<strong>of</strong>essionals, as advocated inSupporting people <strong>with</strong> long-term conditions. 10 Ways <strong>of</strong><strong>working</strong> <strong>with</strong> GPs are constantly evolving, asrecommended in a joint statement by the <strong>Royal</strong> <strong>College</strong><strong>of</strong> Physicians (RCP) and the <strong>Royal</strong> <strong>College</strong> <strong>of</strong> GeneralPractitioners. 11 General practitioners <strong>with</strong> a specialinterest (GPwSIs) in RM participate in many stages <strong>of</strong>rehabilitation.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality RM service provides equitable access tospecialist services for all, including those <strong>with</strong> the mostsevere disabilities. The services described here must beavailable <strong>with</strong>in reasonable distance <strong>of</strong> a patient’s homerather than exclusively in specialist centres.Home-based intervention is therefore essential.Inpatient and outpatient services must be available forthose <strong>with</strong> brain or spinal cord injury, other acute orprogressive neurological conditions, limb deficienciesand rarer disabilities. Stroke rehabilitation should beprovided either by the RM service or <strong>with</strong> RMconsultant input. A consultant in RM must be involvedin providing complex assistive technologies, includingenvironmental controls and special seating.RM services must be based <strong>with</strong>in a well-managed,adequately resourced MDT. Factors that determine206 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Rehabilitation medicineservice quality include committed management,involvement <strong>of</strong> service users and regular audit.Inpatient unitThe BSRM recommends 45–65 beds per millionpopulation for specialist RM, depending on local servicepatterns for stroke and rehabilitation <strong>of</strong> older people. The minimum size <strong>of</strong> a viable inpatient unit shouldbe 20 beds, which should be located together t<strong>of</strong>oster rehabilitation nursing expertise. Space must be available for therapy, recreation,social activities, team meetings and case conferences. The unit requires immediate access to acute medicaland surgical services, dietetics and enteral feedingservices, and radiology and pathology services. Manual and powered wheelchairs must be availableon the unit, and there must be access to specialistorthotics and wheelchair clinics.Outpatient facilitiesMost <strong>patients</strong> need access to the MDT, as well asmedical clinics, so day assessments, case conferencesand outreach visits are <strong>of</strong>ten required. The RMconsultant will need access to services for: physiotherapy and hydrotherapy occupational therapy, including domestic facilitiesand workshops social services information technology (IT) equipment ands<strong>of</strong>tware for patient use orthotics and prosthetics specialist wheelchairs and seating electronic assistive technology driving assessment and training counselling and psychology sexual and genetic counselling education and employment training vocational rehabilitation.Work to maintain and improve the quality <strong>of</strong> careThe role <strong>of</strong> the RM consultant in leading servicedevelopmentsThe work <strong>of</strong> the RM consultant includes more servicedevelopment than that <strong>of</strong> most other specialists, as theylead or contribute to the development <strong>of</strong> care pathways –for example, the current development <strong>of</strong> major traumanetworks in England.<strong>Consultant</strong>s in RM make major contributionsto productivity and quality (as exemplified in Englandby the Quality, Innovation, Productivity and Prevention(QIPP) programme). 12 Respiratory medicinereduces hospital usage by using preventive interventionsalongside general practice and community services, andby coordinating complex hospital discharges. <strong>Consultant</strong>sin RM could play a larger role given the increaseddrive to bring cohesion to rehabilitation services. 13<strong>Consultant</strong>s in RM focus on maintaining and regainingemployment, 14 contributing to the agenda <strong>of</strong> theinterdepartmental strategy Health, work andwell-being. 15<strong>Consultant</strong>s in RM lead undergraduate andpostgraduate teaching on disability andrehabilitation.Education, training and continuing pr<strong>of</strong>essionaldevelopment (CPD)The training curriculum for RM 16,17 includesdeveloping skills in the management <strong>of</strong> neurologicaland musculoskeletal disorders and comorbidities arisingfrom multiple trauma or chronic immobilisation.<strong>Consultant</strong>s must also have a thorough understanding<strong>of</strong> how individual and social behaviours influencedisability. Such training overlaps <strong>with</strong> psychiatry,neurology and neuropsychology. Training must deliverhigh-level skills in communicating <strong>with</strong> individuals andgroups, analysing complex situations and incorporatingpsychological elements in therapeutic interventions.The BSRM organises an annual programme <strong>of</strong> scientificmeetings, postgraduate courses and regionaleducational meetings. The scientific meetings <strong>of</strong> theSociety for Research in Rehabilitation are anotherimportant element in CPD.Clinical governanceClinical governance raises specific issues for RM, 18including the vulnerability <strong>of</strong> people <strong>with</strong> physical andcognitive impairments and medical accountability in anenvironment in which consultant roles may be obscuredby the multidisciplinary interagency context <strong>of</strong> RM.ResearchEvaluating complex interventions has been fundamentalin rehabilitation research for the past two decades,particularly in the development <strong>of</strong> outcome measures.Most evidence for the effectiveness <strong>of</strong> rehabilitationconcerns stroke, but evidence is emerging in acquiredbrain injury, MS and community-orientedC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 207


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>rehabilitation. 8,9,19,20 Gaps remain, however, and theacademic base <strong>of</strong> RM needs further development. Atpresent there are two pr<strong>of</strong>essorial chairs in RM in theUK. A third is anticipated. There are a number <strong>of</strong>non-pr<strong>of</strong>essorial academic posts as well.Local management dutiesRM consultants have a high and complex managementworkload: first, through involvement in servicedevelopment; second, because RM consultants interface<strong>with</strong> a wide range <strong>of</strong> services including therapies,neurosciences and community services; and third,because responsibilities must be shared among smallconsultant teams.Specialty and national guidelinesThe BSRM is the principal focus for nationally basedwork; it regularly produces reports and guidelines.The national clinical guidelines for rehabilitationfollowing acquired brain injury, 21 published jointly bythe RCP and the BSRM, provide a comprehensiveframework for the management <strong>of</strong> an important patientgroup. These evidence-based guidelines will continue tounderpin the development <strong>of</strong> rehabilitation services.The BSRM has published standards for specialistinpatient and community rehabilitation services, 22amputee and prosthetic rehabilitation, 23 spinal cordinjury, 24 use <strong>of</strong> botulinum toxin in spasticity 25 andvocational rehabilitation. 26Guidelines published by the National Institute forHealth and Care Excellence (NICE) on the management<strong>of</strong> MS in primary and secondary care 27 (which providea framework for specialist services in MS, includingaspects most frequently undertaken by RM consultants)and on rehabilitation after critical illness 28 are <strong>of</strong> centralsignificance for the specialty.The National service framework for long-term conditions(2005) specified a 10-year implementationprogramme. 5 Rehabilitation medicine has key roles inthe delivery <strong>of</strong> all <strong>of</strong> the NSF’s Quality Requirements.Specialty and national auditThe BSRM has led development <strong>of</strong> the standardsoutlined below. Most audit work is carried out locally,but the BSRM piloted a peer-review scheme. Guidelinespublished by the BSRM strongly influence local auditactivity, and the BSRM is currently developingspecialty-appropriate parameters for Payment byResults. 29Quality standards and measures <strong>of</strong> the quality <strong>of</strong>specialist servicesMuch work has established measurable quality standardsfor RM. 18 Two standards ratified by the RCP are:1 For all <strong>patients</strong> entering a rehabilitation programme,a set <strong>of</strong> goals should be established and agreedbetween the team and the patient/family <strong>with</strong>in adefined time from entry.2 For all <strong>patients</strong> enrolled in a rehabilitationprogramme, at least one agreed outcome measureshould be assessed on admission and discharge fromthe programme.The BSRM has developed a ‘basket’ <strong>of</strong> approvedoutcome measures, 30 because no single outcomemeasure is appropriate for all types <strong>of</strong> rehabilitation.The Barthel Index and Functional IndependenceMeasure are widely used. Goal attainment scoring isbeing explored as a patient-centred outcome measure.6 Clinical work <strong>of</strong> consultants inrehabilitation medicineHow a consultant works in rehabilitation medicineInpatient workJob plans for consultants in RM vary widely; aconsultant <strong>working</strong> in a post-acute rehabilitation facilitywill have a different emphasis from one <strong>working</strong> in acommunity setting. Draft model job specifications andjob plans for different settings are available from theBSRM. A typical consultant’s <strong>working</strong> week includes: Ward rounds: a conventional weekly medical wardround for 20 beds takes about 3 hours. Inpatient MDT meeting: a rehabilitation unit holdsat least one weekly MDT meeting to discuss patientprogress, which takes at least 3 hours. Referral work: 5–10 referrals may be seen per week,which requires 1–2 programmed activities (PAs)(more if <strong>of</strong>fsite travel is required). Interdisciplinary liaison: liaising between members <strong>of</strong>the MDT and between the numerous medical andsurgical specialties involved requires about 2 PAs perweek. Case conferences: 2–3 cases conferences may be heldper week, which last 1–2 hours (1 PA).Outpatient work Outpatient clinics: 2–5 new <strong>patients</strong> or 4–8follow-up <strong>patients</strong> may be seen in a session <strong>of</strong> 1 PA,based on each new patient requiring 45–60 minutes,and each follow-up 30–35 minutes.208 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Rehabilitation medicine Special clinics: examples <strong>of</strong> these include:– young adults clinic– prosthetic amputee rehabilitation clinic– specialised wheelchair and/or seating clinic– environmental control assessment clinic– spasticity clinic– incontinence clinic– diagnosis-specific clinics, eg MS clinics. Specialist investigative and therapeutic procedureclinics: these include clinics for botulinum toxin,phenol blockade and gait analysis.Specialist on callA consultant may be on call for in<strong>patients</strong> one in two orone in three nights, but is unlikely to need to come intothe hospital more than once a month.Other specialist activity including activitiesbeyond the local service<strong>Consultant</strong>s in RM <strong>of</strong>ten link <strong>with</strong> appropriatespecialties,aslistedinsection4.Clinically related administrationIn RM, assessments are complex; clinics <strong>of</strong>ten involveletters to numerous services and agencies, whichrequires at least half the duration <strong>of</strong> the clinic inaddition to the clinic itself. At least 1 PA per weekshould be allocated for administration.<strong>Consultant</strong>s in RM participate in negotiating fundingfor complex care packages and liaising <strong>with</strong> primarycare trusts, social services and others. Reports onphysical and mental capacities, employment, benefits,insurance, etc, are also frequently required.Community work<strong>Consultant</strong>s in RM increasingly undertake outreach ornetwork-based activity to support specialist teams inthe community. Activities include: MDT meetings (including interagency liaison) outreach clinics home visits (1 PA for 3 or 4 visits) scheduled visits to specialist nursing homes.wide-ranging needs, the practice <strong>of</strong> RM exemplifiesinteragency communication and cooperation.Vocational rehabilitation entails close relationships <strong>with</strong>other agencies, including employers.8 Workforce requirements: clinical andsupport staffCurrent consultant and trainee numbersThere are 177 whole-time equivalent (WTE) RMconsultants. 1 More than 90% <strong>of</strong> RM consultants areemployed full time. Development <strong>of</strong> new consultantposts is proving difficult due to current pressures tomeet government spending targets.There are about 65 specialty trainee (ST) posts in UK.National training numbers (NTNs) have remainedstatic although in common <strong>with</strong> other medicalspecialties RM is facing under-recruitment to STposts. This has implications for future consultantposts.Estimated requirement for consultantsThe BSRM recommends a minimum <strong>of</strong> 1.5 WTEconsultants per 250,000 <strong>of</strong> the population, including0.9 WTE consultants for inpatient and out<strong>patients</strong>ervices and 0.6 WTE consultants for communityprovision. This requires 195 WTE consultants forEngland (233 for the UK), which is an increase <strong>of</strong>approximately 32% on current numbers. Additionalconsultants are required for <strong>patients</strong> <strong>with</strong> highlycomplex needs. Current numbers are thus little over half<strong>of</strong> what is required. Over a 10-year period, RM hasshown the second highest expansion rate at about 150%(Census 1993 to Census 2003), 31 but the currentshortfall remains urgent. Developing new consultantposts is in line <strong>with</strong> the National service framework forlong-term conditions (Quality Requirements 4, 5 and6). 5 The NSF also stipulates the need for networks <strong>of</strong>services that are close to <strong>patients</strong>’ homes for <strong>patients</strong><strong>with</strong> highly complex disabilities. In some parts <strong>of</strong> theUK (especially metropolitan areas) such networks havedeveloped to reflect a mix <strong>of</strong> ‘complex specialised’,district specialist and local general services.7 Opportunities for integrated care<strong>Consultant</strong>s in RM have exceptionally well-developedlinks <strong>with</strong> community health and social services.Because people <strong>with</strong> complex disabilities haveNon-medical workforceThere is a parallel requirement for non-medical staff, asan RM consultant cannot practise effectively <strong>with</strong>outaccess to appropriate numbers <strong>of</strong> specialist nurses,therapists and clinical psychologists.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 209


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Example <strong>of</strong> a job plan (England)Activity Workload Programmed activities (PAs)Direct clinical careInpatient ward rounds 20 in<strong>patients</strong> 1 per ward roundReferrals 10–12 <strong>patients</strong> per week 1–2 (more if <strong>of</strong>fsite travel is required)MDT meeting/case conference, etc Variable 2–4Outpatient clinics, including specialisedclinics45–60 mins per new patient and30–45 mins for follow-up <strong>patients</strong>1 per clinicOutreach work from base hospital Variable 1–2 (more if this is a key focus <strong>of</strong>the role)Work in another specialty Not <strong>of</strong>ten required –Work in general medicine/acute take Not <strong>of</strong>ten required –Work in academic medicine Few academic appointments 0–4 (more for formal academicappointments)Clinical administrationTotal number <strong>of</strong> direct clinical care PAsSupporting pr<strong>of</strong>essional activities(SPAs)Work to maintain and improve thequality <strong>of</strong> healthcareOther NHS responsibilities ∗External duties ∗Clinic-related and outreachadministrationEducation and training, appraisal,departmental management and servicedevelopment, audit and clinicalgovernance, CPD and revalidation,researchFor example, medical director/clinicaldirector/lead consultant inspecialty/clinical tutorFor example, work for deaneries/royalcolleges/specialist societies/Department<strong>of</strong> Health or other government bodies, etc1–27.5–8.5 in most contracts2.5 in most contractsLocal agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trust∗ Note: rehabilitation medicine is a small specialty <strong>with</strong> fewer consultants to service the same number <strong>of</strong> roles for colleges, deaneries and Department<strong>of</strong> Health, etc. These will take more time per consultant than in larger specialties.9 <strong>Consultant</strong> work programme/specimenjob planTable 1 broadly indicates activities, a specimen job planand the relevant number <strong>of</strong> PAs.10 Key points for commissioners1 Rehabilitation medicine is an underused resourcethat prevents hospital admissions and reducesunneeded expenditure and length <strong>of</strong> stay duringadmissions. It is key in delivering major traumanetworks and the NICE guidelines on criticalillness.2 Commissioning discussions will be hampered untilrehabilitation elements <strong>of</strong> healthcare are unbundled.Payment for specialist rehabilitation must reflect thecomplexity <strong>of</strong> patient needs.3 The BSRM recommends a minimum <strong>of</strong> sixconsultants per million population to provideboth inpatient and community services, whichrequires a 50% increase in current consultantnumbers.210 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Rehabilitation medicine4 Rehabilitation medicine requires MDTs. A centreshould include at least two RM consultants(single-handed practice is undesirable).5 Rehabilitation medicine must be recognised as aresource for both hospital and community services.Specialist medical involvement is essential whereverdisabilities are complex – for example, amputationrehabilitation. Advice on rehabilitation medicine is<strong>of</strong>ten crucial for cost-effective delivery <strong>of</strong> assistivetechnologies.6 There should be 45–60 beds per million population,depending on how services such as stroke areprovided. The recommended minimum size for aninpatient unit is about 20 beds.7 The special character <strong>of</strong> RM does not fit well <strong>with</strong> astandard medical job plan. In RM, more time mustbe allocated for clinical administration, interagencycoordination, home visits and servicedevelopment.References1 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Medical rehabilitation in2011 and beyond. London: RCP, 2010.2 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Physical disability in 1986and beyond. London: RCP, 1986.3 World Health Organization. WHO Internationalclassification <strong>of</strong> functioning, disability and health (ICF).Geneva: WHO, 2007. www.who.int/classifications/icf/en/[Accessed 28 June 2011].4 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Long-term neurologicalconditions: management at the interface betweenneurology, rehabilitation and palliative care.Nationalguidelines. Concise guidance series No 10. London: RCP,2008.5 Department <strong>of</strong> Health. National service framework forlong-term conditions. London: DH, 2005. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 4105361 [Accessed28 June 2011].6 Department <strong>of</strong> Health. Transforming communityequipment services: enabling new patterns <strong>of</strong> provision.London: DH, 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 093197 [Accessed 28 June 2011].7 Department <strong>of</strong> Health. Equity and excellence: liberatingthe NHS. London: DH, 2010. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 117353 [Accessed 28 June 2011].8 Turner-Stokes L, Disler P, Nair A, Sedki I, Wade D.Multi-disciplinary rehabilitation for acquired braininjury in adults <strong>of</strong> <strong>working</strong> age. Cochrane Database SystRev 2005;(3):CD004170.9 KhanF,Turner-StokesL,NgL,KilpatrickT.Multi-disciplinary rehabilitation for adults <strong>with</strong> multiplesclerosis. Cochrane Database Syst Rev 2007;(2):CD006036.10 Department <strong>of</strong> Health. Supporting people <strong>with</strong>long-term conditions. An NHS and social care model tosupport local innovation and integration. London: DH,2005. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH4100252 [Accessed 28 June 2011].11 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> GeneralPractitioners. Making the best use <strong>of</strong> doctors’ skills – abalanced partnership. London: RCP, 2006.12 Department <strong>of</strong> Health. The operating framework for theNHS in England 2011/12. London: DH, 2010.www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 122738 [Accessed28 June 11].13 Black A. The future <strong>of</strong> acute care. NHS Confederation.Clin Med 2005;4:10–12.14 Department <strong>of</strong> Health. Healthy lives healthy people: ourstrategy for public health in England. London: DH, 2010.www.dh.gov.uk/en/Publichealth/Healthyliveshealthypeople/index.htm [Accessed 28 June 2011].15 Department <strong>of</strong> Health, Department for Work andPensions, Health and Safety Executive. Health, work andwell-being – caring for our future. London: HM Government,2006. www.dwp.gov.uk/docs/health-andwellbeing.pdf[Accessed 28 June 2011].16 British Society <strong>of</strong> Rehabilitation Medicine.Undergraduate medical education in rehabilitationmedicine. London: BSRM, 2006.17 Joint <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians Training Board.Specialty training curriculum for rehabilitation medicine.London: JRCPTB, 2010. www.jrcptb.org.uk/specialties/ST3-SpR/Documents/2010%20Rehabilitation%20Medicine%20Curriculum.pdf [Accessed 28 June 2011].18 Turner-Stokes L. Clinical governance in rehabilitationmedicine. The state <strong>of</strong> the art in 2002. Clin Rehabil2002;16(suppl 1):13–20.19 Barnes MP, Radermacher H. Community rehabilitation.Cambridge: Cambridge University Press, 2003.20 Turner-Stokes L. The effectiveness <strong>of</strong> rehabilitation: acritical review <strong>of</strong> the evidence. Introduction. Clin Rehabil1999;13(suppl 1):3–6.21 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians, British Society <strong>of</strong>Rehabilitation Medicine. Rehabilitation followingacquired brain injury. National clinical guidelines.London: RCP, 2003.22 British Society <strong>of</strong> Rehabilitation Medicine. Standards forspecialist inpatient and community rehabilitation services.London: BSRM, 2002. www.bsrm.co.uk/ClinicalGuidance/ClinicalGuidance.htm [Accessed 6 June2011].C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 211


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>23 British Society <strong>of</strong> Rehabilitation Medicine. Amputee andprosthetic rehabilitation – standards and guidelines.London: BSRM, 2003.24 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians, British Society <strong>of</strong>Rehabilitation Medicine. Chronic spinal cord injury:management <strong>of</strong> <strong>patients</strong> in acute hospital settings.London:RCP, 2008.25 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Spasticity in adults:management using botulinum toxin. National guidelines.London: RCP, 2008.26 British Society <strong>of</strong> Rehabilitation Medicine. Vocationalassessment and rehabilitation for people <strong>with</strong> long-termneurological conditions: recommendations for best practice.London: BSRM, 2010.27 National Institute for Health and Care Excellence.Multiple sclerosis: management <strong>of</strong> multiple sclerosis inprimary and secondary care. Clinical guideline 8. London:NICE, 2003.28 NICE. Rehabilitation after critical illness. Clinicalguideline 83. London: NICE, 2009.29 Turner-Stokes L, Sutch S, Dredge R. Healthcare tariffs forspecialist inpatient neurorehabilitation services: rationaleand development <strong>of</strong> a UK casemix and costingmethodology. Clin Rehabil (in press).30 Skinner A, Turner-Stokes L. The use <strong>of</strong> standardisedoutcome measures in rehabilitation centres in the UK.Clin Rehabil 2006;20:609–15.31 <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians. Census <strong>of</strong> consultant<strong>physicians</strong> in the UK, 2003: data and commentary.London: RCP, 2003.212 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Renal medicineRenal medicineDr Charles R V Tomson MA BMBCh FRCP DM <strong>Consultant</strong> nephrologistDr Philip D Mason BSc PhD MBBS FRCP <strong>Consultant</strong> nephrologist1 Description <strong>of</strong> the specialtyRenal medicine, or nephrology, involves the care <strong>of</strong><strong>patients</strong> <strong>with</strong> all forms <strong>of</strong> kidney disease. Majorcomponents <strong>of</strong> the service are the management <strong>of</strong><strong>patients</strong> <strong>with</strong> acute kidney injury (AKI; this term hasnow replaced the previous terminology <strong>of</strong> acute renalfailure) or advanced chronic kidney disease (CKD); thelatter is <strong>of</strong>ten used to assess workforce requirements. Inaddition, renal <strong>physicians</strong> provide care for <strong>patients</strong> <strong>with</strong>kidney diseases <strong>with</strong>out impairment <strong>of</strong> excretory kidneyfunction, including proteinuria and nephroticsyndrome, kidney involvement in multisystem immunediseases such as systemic lupus erythematosus andvasculitis, and inherited and acquired tubular and othermetabolic disorders that affect the kidney. Renal<strong>physicians</strong> work closely <strong>with</strong> urologists to provide carefor <strong>patients</strong> <strong>with</strong> haematuria, recurrent infections <strong>of</strong> theurinary tract, kidney stone disease, urinary tractobstruction and neurogenic bladder, and <strong>with</strong>obstetricians to manage kidney disorders in pregnancy,rheumatologists to manage systemic vasculitis andcardiologists to manage ‘cardiorenal syndrome’. Thecare <strong>of</strong> children <strong>with</strong> kidney disease is coordinated bypaediatric renal <strong>physicians</strong>, and particular support isrequired for the transition from paediatric to adult renalservices.A growing aspect <strong>of</strong> the work <strong>of</strong> renal <strong>physicians</strong>, inpartnership <strong>with</strong> primary care and some secondary carespecialties, involves the early detection <strong>of</strong> kidneyproblems and the prevention and management <strong>of</strong>progressive kidney disease.Who are the <strong>patients</strong>?It has become apparent in recent years that kidneydisease is more common than previously appreciated,although some controversies remain around thedefinition <strong>of</strong> CKD and, in particular, the extent to whichreduction in glomerular filtration rate is an inevitableand normal part <strong>of</strong> the ageing process, rather than beingcaused by avoidable microvascular disease. Kidneydisease is a long-term condition for many <strong>patients</strong> andcan impact on all aspects <strong>of</strong> life. The care, support andtreatment <strong>of</strong> <strong>patients</strong> <strong>with</strong> end-stage kidney failure areimportant aspects <strong>of</strong> renal service provision for adults.A coordinated approach involving a wide range <strong>of</strong>healthcare pr<strong>of</strong>essionals is required to ensure thatnutritional, lifestyle, social and psychological needs aremet, alongside the management <strong>of</strong> biochemical andmetabolic disorders. The complexity <strong>of</strong> this carerequires integrated multipr<strong>of</strong>essional <strong>working</strong> toprovide a high-quality service.A sustained increase has been seen in the number <strong>of</strong><strong>patients</strong> receiving renal replacement therapy (RRT) inthe UK. At the end <strong>of</strong> 2010, 50,965 <strong>patients</strong> werereceiving RRT in the UK, and prevalence per millionpopulation increased from 523 to 832 between 2000 and2010. 1,2 Acceptance rates for <strong>patients</strong> into RRT are lowerin the UK than in other comparable countries, whichmay be due partly to better prevention <strong>of</strong> progressivekidney disease in primary and secondary care, but couldalso be due to unmet need. The main growth in RRT inrecent years has been in hospital-based haemodialysis,<strong>with</strong> a gradual decline in the number <strong>of</strong> <strong>patients</strong>receiving home-based therapies (peritoneal dialysis andhome haemodialysis); current initiatives to enhancepatient choice and promote home therapies can beexpected to make some impact on this. In parallel,significant increases have been seen in the mean age andcomorbidities <strong>of</strong> <strong>patients</strong> accepted to RRT programmes.Rates <strong>of</strong> kidney transplantation have grown byincreasing use <strong>of</strong> transplantation from living kidneydonors, including spouses, friends, and altruisticdonors, from donation after circulatory death donors,and from ‘expanded criteria’ donors. Renaltransplantation across ABO blood group barriers oracross human leukocyte antigen (HLA)incompatibilities, traditionally rather uncommon in theUK, is becoming more widespread now that moderntechniques have led to improved results, but requiresadditional up-front funding. Renal <strong>physicians</strong> workclosely <strong>with</strong> transplant surgeons in the provision <strong>of</strong>renal transplant services, and are involved in theassessment <strong>of</strong> potential recipients, the evaluation <strong>of</strong>potential living donors, preoperative and postoperativeC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 213


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>care, and the long-term follow-up <strong>of</strong> <strong>patients</strong> afterkidney transplantation.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceAccess to renal services is required at primary,secondary and tertiary levels at different stages in thejourney <strong>of</strong> a patient <strong>with</strong> kidney disease.Sources <strong>of</strong> referral from primary careThe early detection and prevention <strong>of</strong> CKD requireclose collaboration <strong>of</strong> primary care practitioners, renal<strong>physicians</strong> and other specialists in secondary care.Awareness that CKD and/or proteinuria is a major riskfactor for vascular disease is increasing. Ascertainment<strong>of</strong> kidney disease will undoubtedly be increased bystandardisation <strong>of</strong> assessment <strong>of</strong> excretory kidneyfunction using estimated glomerular filtration rate(eGFR) and by more widespread testing foralbuminuria. The eGFR is calculated from serumcreatinine, age, gender and ethnic origin, and is nowroutinely reported (after adjustment for interassaydifferences) by all NHS clinical biochemistrylaboratories whenever a serum creatinine concentrationis reported.Many people <strong>with</strong> CKD will not develop progressivekidney failure, and the emphasis should be on themanagement <strong>of</strong> their vascular risk factors in primarycare. An important minority <strong>of</strong> <strong>patients</strong> <strong>with</strong> CKD willprogress towards end-stage kidney failure, however, andlate referral <strong>of</strong> such <strong>patients</strong> remains a problem. Those<strong>with</strong> progressive CKD will benefit from specialistreferral for management to delay progression and tomanage the complications <strong>of</strong> progressive CKD,including anaemia, acidosis and bone disease.Guidelines on the detection, management and referral<strong>of</strong> <strong>patients</strong> <strong>with</strong> CKD in the UK provide clear guidanceon the management <strong>of</strong> CKD, including indications forreferral to a renal physician. 3 The National Institute forHealth and Care Excellence (NICE) has recentlypublished guidance on this topic(www.nice.org.uk/CG73). 4 Although detection <strong>of</strong> CKDin primary care is increasing, correct application <strong>of</strong>these guidelines has not resulted in a major sustainedincrease in the rates <strong>of</strong> outpatient referral to renalmedicine: many <strong>patients</strong> <strong>with</strong> stable, uncomplicatedCKD can safely be managed in primary care.Sources <strong>of</strong> referral from secondary andtertiary careThe provision <strong>of</strong> care for <strong>patients</strong> <strong>with</strong> advanced CKDand end-stage kidney failure is largely based in hospital.Referrals to secondary care arise from GPs and otherspecialists in secondary care, particularly diabetologists,cardiovascular <strong>physicians</strong>, rheumatologists andurologists.‘Acute kidney injury (AKI)’ is now the preferred termfor an acute change in kidney function, The change interminology is driven by the recognition that the earlystages <strong>of</strong> AKI are avoidable, primarily by the promptrecognition and treatment <strong>of</strong> sepsis, hypotension andhypovolaemia, together <strong>with</strong> the promptdiscontinuation (using ‘sick day rules’) <strong>of</strong> drugs thatmay impair renal autoregulation in the face <strong>of</strong> suchinsults – including drugs widely used in themanagement <strong>of</strong> chronic heart failure, hypertension andCKD (eg angiotensin-converting enzyme (ACE)inhibitors, angiotensin receptor blockers). Mostepisodes <strong>of</strong> AKI occur in other specialties (eg acutegeneral medicine, cardiology, general surgery), but renal<strong>physicians</strong> have an important role to play in ensuringthat appropriate education and clinical systems (egautomated laboratory-based recognition <strong>of</strong> AKI) are inplace. Patients <strong>with</strong> later stages <strong>of</strong> AKI are eithermanaged by nephrologists (providing dialysis) or on anintensive care unit (usually <strong>with</strong> continuoushaem<strong>of</strong>iltration). Patients who have had an episode <strong>of</strong>AKI are at greater risk <strong>of</strong> further episodes and <strong>of</strong>developing CKD, even if they appear initially to fullyrecover renal function.During the 1960s and 1970s, programmes for RRT inthe UK were provided by a small number <strong>of</strong> renal unitsbased in tertiary referral centres that covered largecatchment populations. In the 1980s and 1990s, asignificant increase in provision <strong>of</strong> dialysis was seen,provided to some extent by an increase in satellite unitsbut also by growth in the number <strong>of</strong> renal units.Currently there are 52 main adult renal units (notincluding satellite units) in England, 9 in Scotland, 5 inWales and 5 in Northern Ireland. There are 207 satellitedialysis units in the UK; 76 <strong>of</strong> these are operated byprivate companies under contract to the NHS, but, eventhough the nurses in these units are employed privately,medical supervision <strong>of</strong> the care <strong>of</strong> <strong>patients</strong> receivingdialysis in these units is provided by NHS nephrologists.A smaller number <strong>of</strong> these hospitals have renaltransplant units (RTUs), which also provide surgicaltransplant services: 19 in England, 23 in the UK.214 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Renal medicineLocal and regional servicesClinical networksThe level <strong>of</strong> renal service provision in different hospitalsvaries considerably. Some district general hospitals(DGHs) do not have a consultant renal physician.Others have a renal physician on a sessional basis,perhaps providing support for a satellite haemodialysisunit and outpatient clinic work, <strong>with</strong> 24-hour cover forrenal problems provided by the nearest renal unit. Agrowing number <strong>of</strong> DGHs have renal units that havesufficient consultant renal <strong>physicians</strong> to provide both24-hour specialist cover for renal medicine and on-callcover for general internal medicine (GIM), but requireaccess to a tertiary centre for renal transplantation.Continuous RRT (by haem<strong>of</strong>iltration or haemodiafiltration)for the urgent management <strong>of</strong> AKI can beperformed in many intensive care units (ICUs); <strong>patients</strong>who require continuous RRT may need to betransferred to a renal unit if RRT is still needed whenintensive care is no longer required. Delay in transfer isassociated <strong>with</strong> poorer outcomes and there is increasingdemand for formal agreements between hospitals in aclinical network to ensure timely and safe transfer <strong>of</strong><strong>patients</strong> <strong>with</strong> AKI.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong>Involving <strong>patients</strong> in decisions about theirtreatmentThe diagnosis <strong>of</strong> progressive CKD will be a majorlife-changing event. The needs <strong>of</strong> <strong>patients</strong> and theirfamilies and carers should be assessed on a regular basisto ensure that appropriate support is provided so thatthey can be involved in decisions about treatment. Theconsultant renal physician is central to ensuring thatoptimum support is provided by the multipr<strong>of</strong>essionalteam and that <strong>patients</strong> have access to the knowledge andexpertise that they require. Many decisions facing<strong>patients</strong> <strong>with</strong> kidney disease are ‘preference sensitive’ –the choice depends not just on clinical outcomes butalso on the patient’s values and preferences. Elicitingthese, and ensuring that the patient ‘shares’ thedecision, rather than passively accepting a decisionmade by the healthcare team, requires specificconsultation skills. This is particularly important whenconsidering RRT for <strong>patients</strong> <strong>with</strong> end-stage kidneyfailure. Older <strong>patients</strong> <strong>with</strong> significant comorbidityother than CKD derive minimal or no survival benefitfrom dialysis: for such <strong>patients</strong>, the decision whether tostart dialysis is analogous to deciding whether to havechemotherapy to extend life in incurable cancer.Renal units provide information to <strong>patients</strong> and theircarers through direct discussions <strong>with</strong> members <strong>of</strong> themultipr<strong>of</strong>essional team – individually or in groupsessions – and through written and audiovisualmaterials. Patient decision aids are used as part <strong>of</strong> the‘shared decision-making approach’ and can be paper orweb based. Patients who feel ‘in control’ <strong>of</strong> their illnessdo better than those who feel that their illness controlsthem, so investment <strong>of</strong> effort to ‘empower’ <strong>patients</strong> payslarge dividends. Most UK renal units <strong>of</strong>fer <strong>patients</strong>access to their own test results and clinic letters usingRenal Patient View 5 – an award-winning, web-basedaccess system that so far is unique to renal medicine.Patients should be <strong>of</strong>fered opportunities for self-carewhenever possible. Peritoneal dialysis and homehaemodialysis <strong>of</strong>fer greater opportunities forindependence and self-determination, but decisionsabout treatment must take into account the impact oncarers and the patient’s home and family life.Patient choice: cultural considerationsPatients need time and expert advice to help them deal<strong>with</strong> diverse choices, which may include opting forhome-based dialysis treatment, hospital-based dialysisor pre-emptive living donor transplant or, for some,choosing not to receive dialysis or a transplant whenkidney failure supervenes and instead opting forconservative care. Such discussions can be complex andtime-consuming. The need to provide information in arange <strong>of</strong> languages appropriate to the local populationandtotakeaccount<strong>of</strong>religiousneeds–egwhenconsidering dietary advice – is widely recognised.Patient support groupsMany renal units have active kidney disease associationsthat provide local information and support. Thecontrolling council <strong>of</strong> the National Kidney Federation(NKF, www.kidney.org.uk) brings together 63 kidney<strong>patients</strong>’ associations. The NKF campaigns forimprovements to renal provision and treatment, andprovides support and information for <strong>patients</strong> throughits website, information leaflets on kidney disease andthe National Kidney Patients’ Helpline. The BritishKidney Patient Association (www.britishkidney-pa.co.uk) provides support, information and grant aidboth to individuals and to renal centres, as well assupporting research that is likely to be <strong>of</strong> direct benefitC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 215


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>to <strong>patients</strong>. There is an active discussion forum onwww.kidneypatientguide.org.uk. Kidney Research UKalso provides valuable patient information(www.kidneyresearch.uk.org).interventional skills for the provision and maintenance<strong>of</strong> vascular access. Recommendations for theorganisation <strong>of</strong> services for vascular and peritonealaccess have recently been published. 6,74 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>During the course <strong>of</strong> their illness, <strong>patients</strong> <strong>with</strong> kidneydisease encounter numerous healthcare pr<strong>of</strong>essionals,who each contribute to their management and care.Patients’ varied needs may form the focus, at differenttimes, for a wide range <strong>of</strong> healthcare pr<strong>of</strong>essionals <strong>with</strong>expertise in kidney disease: renal <strong>physicians</strong> nurses and healthcare support assistants dietitians social workers clinical psychologists counsellors clinical technologists pharmacists occupational therapists and physiotherapists renal transplant and vascular surgeons transplant coordinators staff <strong>of</strong> the histocompatibility and immunogeneticsservice.Extended roles for clinicians other than doctors havelong been established practice in renal units – eg in theday-to-day care in haemodialysis units. Othercompetence-based extended roles – eg prescribing,nurse-led clinics and placement <strong>of</strong> vascular accesscatheters – are increasingly being developed.Renal unit managers and clerical and administrativestaff also have a key role in supporting patient care.The renal multipr<strong>of</strong>essional team that delivershealthcare to kidney <strong>patients</strong> is represented by a number<strong>of</strong> pr<strong>of</strong>essional bodies, which are coordinated throughthe British Renal Society (BRS, www.britishrenal.org).Access to the circulation or peritoneum forhaemodialysis and peritoneal dialysis, respectively, isessential for provision <strong>of</strong> dialysis. Access for dialysis isbest provided by a multipr<strong>of</strong>essional team whichincludes vascular and transplant surgeons, who areresponsible for the creation <strong>of</strong> access, renal <strong>physicians</strong>,renal nurses, and radiologists <strong>with</strong> vascular imaging andWorking <strong>with</strong> other specialistsRenal <strong>physicians</strong> <strong>of</strong>ten provide support for <strong>patients</strong> whodevelop kidney problems in other units and hospitals,particularly in ICUs, cardiothoracic units, liver unitsand vascular units, where AKI is common. Renal<strong>physicians</strong> play a key educational role in settings inwhich improved clinical practice can reduce the risk <strong>of</strong>AKI, and a recent National Confidential Enquiry intoPatient Outcome and Death (NCEPOD) reportemphasised the need for improvements. 8 Diabetes,microvascular and macrovascular disease, andimmune-mediated kidney diseases are the mostcommon causes <strong>of</strong> CKD, and renal <strong>physicians</strong> need towork closely <strong>with</strong> diabetologists and immunologists.Renal <strong>physicians</strong> also work closely <strong>with</strong> urologists,especially in the management <strong>of</strong> obstructive renaldisease. The multisystem consequences <strong>of</strong> kidneydisease – eg the increased risk <strong>of</strong> cardiovascular diseaseand metabolic bone disease – mean that <strong>patients</strong> <strong>with</strong>kidney failure require the support <strong>of</strong> many otherspecialists. The increasing number <strong>of</strong> elderly <strong>patients</strong> ondialysis programmes <strong>of</strong>ten requires the skills <strong>of</strong>rehabilitation teams, and end-<strong>of</strong>-life issues requirepartnership <strong>with</strong> local palliative care services. Close<strong>working</strong> <strong>with</strong> renal transplant surgeons is essential fordelivery <strong>of</strong> a renal transplant service. Renal pathologistsprovide essential diagnostic input into renal andtransplant services.Working <strong>with</strong> non-consultant medicalpractitionersNon-consultant career grade (NCCG) practitioners playa key role in the provision <strong>of</strong> care in many renal units,especially for <strong>patients</strong> on maintenance haemodialysis.There are probably around 50 NCCGs <strong>working</strong> in UKrenal units, <strong>of</strong> whom two thirds are associate specialists.Many <strong>of</strong> these individuals are highly experienced.Provision <strong>of</strong> adequate training and study leaveopportunities for these doctors is currentlyunsatisfactory. New opportunities are <strong>of</strong>fered throughArticle14<strong>of</strong>theordergoverningthePostgraduateMedical Education and Training Board (PMETB),which describes how to secure a certificate <strong>of</strong> eligibilityfor specialist registration (CESR). By this means, anumber <strong>of</strong> NCCG doctors are being placed on thespecialist register.216 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Renal medicineInvolvement <strong>of</strong> renal <strong>physicians</strong> in otherspecialty work<strong>Consultant</strong>s whose primary specialty is renal medicinemay work in additional specialties. The most commonadditional specialties declared by renal <strong>physicians</strong> in theRCP’s census <strong>of</strong> consultant <strong>physicians</strong> in 2011 includedgeneral (internal) medicine, acute medicine andtransplantation medicine. Other specialties mentionedwere cardiology, clinical genetics, clinicalneurophysiology, endocrinology, genitourinarymedicine, immunology, intensive care medicine,metabolic medicine, obstetric medicine, paediatriccardiology and rheumatology. 9Working <strong>with</strong> GPs, GPs <strong>with</strong> a special interest(GPwSIs) and the primary care teamRenal <strong>physicians</strong> work closely <strong>with</strong> primary carecolleagues to ensure that pathways for the management<strong>of</strong> CKD are agreed in accordance <strong>with</strong> guidelines in theUK. 3,4 Appropriate locality-based electronicinformation and decision support have been developed.The role <strong>of</strong> GPwSIs in renal medicine has not beendeveloped. The primary care <strong>of</strong> CKD is dominated bymanagement <strong>of</strong> vascular risk, which is mainstreamwork for all GPs. Complex cases will still need referral toa renal physician, although shared-care protocols forongoing management are <strong>of</strong>ten appropriate. Renal<strong>physicians</strong> play a major role in providing educationabout CKD for non-specialists, especially those inprimary care, and in providing leadership as carepathways for CKD emerge <strong>with</strong>in healthcommunities.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality service is one in which <strong>patients</strong> and theirfamilies and carers have timely access to the expertise,advice and support <strong>of</strong> the full range <strong>of</strong> renal healthcarepr<strong>of</strong>essionals <strong>with</strong>in the multipr<strong>of</strong>essional team. Thecharacteristics <strong>of</strong> such a service are described in theNational service framework for renal services forEngland. 10,11 The service should meet the goalsrecommended by the Renal Association’s clinicalpractice guidelines. 12Specialised facilities required fora high-quality serviceRenal units require specialised facilities for outpatienthaemodialysis – at the hospital base <strong>of</strong> the renal unit, insatellite units in other hospitals or freestanding in thecommunity. Specialised wards are also required for thecare <strong>of</strong> in<strong>patients</strong> <strong>with</strong> renal disease, including ahigh-dependency facility and facilities for renaltransplantation. Isolation facilities are required for thecare <strong>of</strong> <strong>patients</strong> <strong>with</strong> highly transmissible diseasesreceiving haemodialysis. The standards for suchfacilities have been laid out. 13Information technologyIn addition, renal units should have the informationtechnology (IT) necessary to perform internal audit andto submit required data to the UK Renal Registry. Mostrenal units are highly computerised, using a range <strong>of</strong> ITsystems. Although these systems are veryheterogeneous, it is possible to use ‘mapping’ s<strong>of</strong>twareto extract data items to external databases, including theRenal Patient View website mentioned above. In thenear future, this mapping and extraction s<strong>of</strong>tware couldbe used to ensure that information could be transferredfrom one renal unit to another if a patient movesaround the country.Maintaining and improving the quality <strong>of</strong> careThis work encompasses duties in clinical governance,pr<strong>of</strong>essional self-regulation, continuing pr<strong>of</strong>essionaldevelopment (CPD), and education and training <strong>of</strong>others. For many consultants at various times in theircareers, it may include research, management, and theprovision <strong>of</strong> specialist advice at local, regional and/ornational levels.Service developments to deliver improved careThe increasing numbers <strong>of</strong> <strong>patients</strong> who need treatmentfor kidney disease underline the importance <strong>of</strong> the renal<strong>physicians</strong>’ role in planning <strong>with</strong> commissioners forexpansion and development <strong>of</strong> services and inevaluating innovative approaches to service delivery.Leadership is usually provided by the clinical director ornetwork lead. Other consultants may need to sharesubstantial local management duties depending on thesize <strong>of</strong> the unit.Education and trainingTraining renal <strong>physicians</strong> to meet the requirements forconsultant expansion is essential, and consultants needsufficient time to supervise and appraise trainees. Allrenal <strong>physicians</strong> are involved in education and training,and many will act as educational supervisors <strong>with</strong>intheir hospital and/or will take on specific roles <strong>with</strong>intheir deanery or for the royal colleges. Renal <strong>physicians</strong>C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 217


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>must also participate in appraisal and CPD, and systemsfor mentoring new consultants are encouraged. Renal<strong>physicians</strong> also play an important part in undergraduateeducation.Research – clinical studies, teachingand basic scienceRenal medicine has a strong track record in teachingand research. Many specialty registrars (StRs) undertakea period <strong>of</strong> formal research training, and many NHSconsultants supervise research alongside academiccolleagues. Academic renal <strong>physicians</strong> <strong>of</strong>ten train inlaboratory science and work closely <strong>with</strong> basic scientists,but renal <strong>physicians</strong> are increasingly involved in a widerange <strong>of</strong> research, including epidemiology, clinicalresearch and healthcare service research, as well aslaboratory studies.Regional and national workParticipation <strong>of</strong> renal <strong>physicians</strong> in regional andnational work is important to ensure that <strong>patients</strong> haveequitable access to a high-quality service across the UKand that opportunities for teaching and research arewidely available. These roles, which are usually for afixed term, can be onerous, and it is essential thatarrangements for cover <strong>of</strong> local duties are agreed <strong>with</strong>colleagues and managers.Collectively, these roles in service development andprovision, audit, education and training, mentoring,appraisal and pr<strong>of</strong>essional development ensure thatrequirements for clinical governance are met. Overallresponsibility for clinical governance usually rests <strong>with</strong>the clinical director.Specialty and national guidelinesSpecialist society guidelines Renal Association clinical practice guidelines 12 Good practice guidelines for renaldialysis/transplantation units: prevention and control<strong>of</strong> blood-borne virus infection 14 Standards for solid organ transplantation in theUnited Kingdom. 15National Institute for Health and Care Excellenceguidelines Renal failure – home versus hospital haemodialysis.Technology appraisal (TA) 48 16 Central venous catheters – ultrasound locating devices.TA49 17 Renal transplantation – immuno-suppressiveregimens (adults). TA85 18 Type 2 diabetes: the management <strong>of</strong> type 2 diabetes(update). Clinical guideline (CG) 66 19 Renal transplantation – immunosuppressive regimensfor children and adolescents. TA099 20 Laparoscopic insertion <strong>of</strong> peritoneal dialysis catheters.Interventional procedures guidance (IPG) 208 21 Cinacalcet for the treatment <strong>of</strong> secondaryhyperparathyroidism in <strong>patients</strong> <strong>with</strong> end-stagerenal disease on maintenance dialysis therapy.TA117 22 Chronic kidney disease: early identification andmanagement <strong>of</strong> chronic kidney disease in adults inprimary and secondary care. CG73 4 Type 2 diabetes: the management <strong>of</strong> type 2 diabetes.CG87 (partial update <strong>of</strong> CG66) 23 Peritoneal dialysis: peritoneal dialysis in the treatment<strong>of</strong> stage 5 chronic kidney disease. CG125 24 Chronic kidney disease. Quality Standard (QS) 5 25 Anaemia management in people <strong>with</strong> chronic kidneydisease. CG114 26 Percutaneous transluminal radi<strong>of</strong>requencysympathetic denervation <strong>of</strong> the renal artery forresistant hypertension. IPG418 27 Hyperphosphataemia in chronic kidney disease:management <strong>of</strong> hyperphosphataemia in <strong>patients</strong> <strong>with</strong>stage 4 or 5 chronic kidney disease. CG157 28 Acute kidney injury: prevention, detection andmanagement <strong>of</strong> acute kidney injury up to the point <strong>of</strong>renal replacement therapy. CG [In press] 29Department <strong>of</strong> Health guidance Renal specific management <strong>of</strong> medicines 30 Reducing MRSA and other healthcare-associatedinfections in renal medicine. 31Quality tools and frameworksThe performance <strong>of</strong> renal units against these guidelinesis audited for <strong>patients</strong> on RRT through the annualreports <strong>of</strong> the Renal Association’s UK Renal Registry(www.renalreg.org), for which data are returned fromall renal units in the UK. There is some evidence <strong>of</strong>sustained improvements in the quality <strong>of</strong> service in anumber <strong>of</strong> areas for which the registry publishescomparative data – eg the management <strong>of</strong> renalanaemia and the control <strong>of</strong> hyperphosphataemia.However, substantial unexplained variation remains,and the role <strong>of</strong> the registry is anticipated to expand intocontinuous quality improvement.218 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Renal medicineAcademic medicineThe RCP’s census <strong>of</strong> 2011 identified 540 consultants inrenal medicine in the UK. 9 Of these, 11% whoresponded held at least some academic sessions.6 Clinical work <strong>of</strong> consultantsInpatient workEmergency workEmergency work involves: treatment <strong>of</strong> AKI investigation and management <strong>of</strong> fluid andelectrolyte disorders medical emergencies arising among <strong>patients</strong> on RRT.As well as care <strong>of</strong> <strong>patients</strong> on renal wards, this worktypically involves consulting on <strong>patients</strong> in other wardsand other hospitals, both in person and by provision <strong>of</strong>telephone advice.Investigative inpatient nephrologyThis relates to work associated <strong>with</strong> the immunologicaland metabolic nature <strong>of</strong> kidney disease, which involvesinvestigative procedures in an inpatient setting.Specialist procedures include renal biopsy; a renal unitcan expect to perform 150–200 renal biopsies permillion population per year.The setting for these beds should always be an acutehospital that <strong>of</strong>fers the full range <strong>of</strong> supporting services,including imaging, pathology, immunology,haematology, biochemistry and microbiology.Different models for providing inpatient care havedeveloped according to local needs and the numbers <strong>of</strong>consultant renal <strong>physicians</strong>. In small units <strong>with</strong> two orfewer consultant renal <strong>physicians</strong>, consultants mayprovide continuing cover for all inpatient aspects <strong>of</strong>renal medicine. In larger units, individual consultantsmay provide continuing cover for subspecialty interests(eg transplantation and vasculitis) or may rotate coverfor all in<strong>patients</strong>, devoting time to other activities (egresearch, management, teaching and audit) when notdirectly involved in inpatient care. The RCP’s <strong>working</strong>party report The changing face <strong>of</strong> renal medicine in theUK: the future <strong>of</strong> the specialty 32 recommended aminimum <strong>of</strong> four consultant renal <strong>physicians</strong> to make arenal unit autonomous for clinical care, includingon-call commitments.The RCP’s Joint Specialty Committee (JSC) for RenalMedicine has recommended that all <strong>patients</strong> admittedto a renal unit should be seen by a consultant <strong>with</strong>in 24hours and that all in<strong>patients</strong> should be reviewed by aconsultant at least twice a week. <strong>Consultant</strong> renal<strong>physicians</strong> should therefore visit the wards daily to seenew admissions and new referrals from other specialtiesand should perform at least two full ward rounds eachweek.Outpatient workRenal replacement therapyA major element <strong>of</strong> the work <strong>of</strong> a renal physicianinvolves preparing <strong>patients</strong> <strong>with</strong> advanced CKD for RRTand providing medical supervision <strong>of</strong> these <strong>patients</strong> forthe remainder <strong>of</strong> their lives. Increasingly, they are alsoinvolved <strong>with</strong> conservative care <strong>of</strong> <strong>patients</strong> opting not toreceive RRT. Resources should be sufficient to supportan annual acceptance rate onto RRT <strong>of</strong> 120–130 new<strong>patients</strong> per million population, <strong>with</strong> free choicebetween modality according to the patient’s needs.Available modalities should include hospital-basedhaemodialysis, home haemodialysis, peritoneal dialysis(including chronic ambulatory peritoneal dialysis(CAPD) and automated peritoneal dialysis (APD)) andkidney and/or pancreas transplantation for a suitableminority. Non-dialysis management requires leadershipby the renal physician <strong>of</strong> a full multipr<strong>of</strong>essional team inliaison <strong>with</strong> palliative care services. The role <strong>of</strong>, andfunding arrangements to support, ‘assisted APD’, inwhich healthcare workers are employed to helpdependent <strong>patients</strong> to perform APD, is being defined.PredialysisPatients <strong>with</strong> progressive renal failure should bemanaged in a clinic <strong>with</strong> multidisciplinary supportfrom dietitians and specialist nurses. Education andpreparation for dialysis, including referral for timelyformation <strong>of</strong> vascular access, should be available.TransplantationIn addition to monitoring and optimising kidneyfunction, renal transplant clinics should providemanagement <strong>of</strong> cardiovascular risk, osteoporosis andpost-transplantation pregnancy, and prevention anddetection <strong>of</strong> malignancy, especially skin cancer.General nephrologyOther outpatient activity is concerned <strong>with</strong> investigationand management <strong>of</strong> the wide range <strong>of</strong> kidney problemsthat do not necessarily lead to progressive CKD. In largeC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 219


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>renal units, further specialist clinics (<strong>of</strong>ten shared <strong>with</strong>other disciplines) may focus on specific clinical issuesfor people <strong>with</strong> kidney disease – eg clinics for people<strong>with</strong> diabetes, pregnancy, lupus and vasculitis.A whole-time equivalent (WTE) consultant renalphysician should expect to work in three clinics perweek, which is likely to reflect a mixture <strong>of</strong> generalnephrology, predialysis, haemodialysis, CAPD, renaltransplant and specialty clinics. The number <strong>of</strong> <strong>patients</strong>seen will vary considerably according to the clinic andthe support staff available. For example, a new patient<strong>with</strong> established kidney failure may require 1 hour <strong>of</strong> aconsultant’s time if seen in a clinic <strong>with</strong>out support staffbut might spend half an hour <strong>with</strong> the consultant andhalf an hour <strong>with</strong> other staff, including a specialist nurseand a dietitian, in a dedicated low clearance clinic.Similarly, a follow-up patient <strong>with</strong> established renalfailure may need to spend 10–30 minutes <strong>with</strong> aconsultant, depending on the availability <strong>of</strong> specialistsupport staff, who might advise on management <strong>of</strong>anaemia, access for dialysis and diet. The need forongoing multidisciplinary specialist input into manylong-term renal conditions means that the ratio <strong>of</strong>follow-up appointments to new patient appointments isunusually high.Specialist investigative proceduresSpecialist procedures undertaken by renal <strong>physicians</strong>include renal biopsy, placement <strong>of</strong> temporary andpermanent central venous catheters, and insertion <strong>of</strong>catheters for peritoneal dialysis. The procedures are<strong>of</strong>ten shared <strong>with</strong> specialist nurses, radiologists andsurgeons.Specialist on callA census <strong>of</strong> all consultant renal <strong>physicians</strong> in 2010reported that 33% have a regular on-call commitmentfor unselected emergency medical admissions (Dr PhilMason, personal communication) – a decrease from52% in the census in 2002 and 40% in 2006. 33,34 On-callwork for renal medicine is <strong>of</strong>ten highly intensive,particularly because <strong>of</strong> the need to support <strong>patients</strong><strong>with</strong> AKI and the complexity <strong>of</strong> intercurrent illness inpeople on RRT. A frequency <strong>of</strong> no more than one infour is recommended.Other specialist activity, including activitiesbeyond the local servicesMany consultant renal <strong>physicians</strong> provide cover forsatellite dialysis units and give telephone advice oraccept referrals from neighbouring hospitals that areunable to provide 24-hour nephrology cover.Advice is increasingly given to <strong>patients</strong>, GPs and otherhealthcare pr<strong>of</strong>essionals by phone or email, which mayobviate or replace outpatient clinic visits. Such ‘virtual’clinical practice, which is in keeping <strong>with</strong> NHScommitments to environmental sustainability, saves thepatient time and money and encourages patient‘empowerment’, must be recognised in consultant jobplans and in contractual arrangements.Clinically related administrationClinical activity in renal medicine <strong>of</strong>ten generatesclinically related administrative duties that can require afurther 50–100% <strong>of</strong> the time spent in direct contact <strong>with</strong><strong>patients</strong>, eg after a renal transplant clinic, the consultantrenal physician will need to check laboratory results forall <strong>patients</strong>, arrange admission or rearrange follow-up ifunexpected results are identified, contact <strong>patients</strong> orGPs concerning any alterations to treatment, anddictate and sign relevant correspondence. This clinicallyrelated administration should be taken into accountwhen time for direct clinical care is allotted inconsultant job plans.7 Opportunities for integrated careAs well as the obvious links <strong>with</strong> transplant surgeonsand vascular access surgeons, renal <strong>physicians</strong> now <strong>of</strong>tenprovide integrated care <strong>with</strong> other specialists: egobstetricians, diabetologists, geriatricians and palliativecare <strong>physicians</strong>. They also typically work inmultidisciplinary teams <strong>with</strong> (for example) dietitians,pharmacists, psychologists, podiatrists, vasculartechnicians, etc.8 Workforce requirements for the specialtyA census <strong>of</strong> all renal units by the RCP’s JSC establishedthat there were 525 consultants in renal medicine(106 women; 404 WTEs dedicated to renal medicine; asmany renal <strong>physicians</strong> also have other commitments,especially GIM or academia) as <strong>of</strong> February 2010(Dr Phil Mason, personal communication).More renal <strong>physicians</strong> are required. The justification forthis statement comes from the recommendations <strong>of</strong> theBRS’s National Renal Workforce Planning Group(2002), 35 which are endorsed by the RCP’s <strong>working</strong>220 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Renal medicineTable 1 Variation in RRT : renal WTE ratio in 2010Area Mean RRT : renal WTE ratio Individual unit RRT : renal WTE ratio rangeUK 110 25–211England 117 25–211Wales 116 62–196Northern Ireland 63 32–112Scotland 89 62–127RRT = renal replacement therapy; WTE = whole-time equivalent.party report The changing face <strong>of</strong> renal medicine in theUK: the future <strong>of</strong> the specialty. 32 On the basis <strong>of</strong> currentpatterns <strong>of</strong> work, <strong>with</strong> support from NCCG doctors,junior doctors, nurses and staff from other pr<strong>of</strong>essionsallied to medicine, it is recommended that one WTErenal physician is required for every 100 RRT <strong>patients</strong> orfor every 75 RRT <strong>patients</strong> for an ‘average’ physician <strong>with</strong>GIM responsibilities. This resulted in a projectedworkforce requirement <strong>of</strong> 570 WTEs by 2010. In fact,the 2002 projection is similar to a more up-to-dateprojection (taken from actual numbers <strong>of</strong> <strong>patients</strong> onRRT on the Renal Registry in 2008) <strong>of</strong> 53,000 <strong>patients</strong>in 2010 (which would require 530 WTEs) and the actualend-2010 figure <strong>of</strong> 50,965 RRT <strong>patients</strong> requiring510 WTEs. This number is slightly lower becausethe rate <strong>of</strong> increase has slowed down from theaverage annual increase <strong>of</strong> 5% between 2000 and2006. The actual current averages fall short <strong>of</strong> this butthere is considerable regional and unit variation(Table 1).These projections assume that the balance betweencommitment to renal medicine and GIM and the extent<strong>of</strong> part-time <strong>working</strong> will remain the same. This ispossibly not a valid assumption, as increasing numbers<strong>of</strong> renal <strong>physicians</strong> are dropping GIM and the number<strong>of</strong> doctors planning to work less than full time isincreasing. In addition, the median contracted timeworked by consultant renal <strong>physicians</strong> currently isequivalent to 11.5 programmed activities (PAs) perweek. To achieve 10 PAs per consultant would need 109more posts.The currency for estimating workforce requirements asdescribed (one WTE renal physician renal physician forevery 100 RRT <strong>patients</strong>) broadly assumes that thesenumbers will effectively cover the range <strong>of</strong> outpatientand inpatient work <strong>of</strong> a ‘typical’ renal physician. It alsotakes into account the service contribution <strong>of</strong> traineesand NCCGs and the demands <strong>of</strong> general medicine,academic commitments and less-than-full-time<strong>working</strong> for personal reasons. Furthermore, there is avision for many more independent renal units,especially in England and Wales, and provision <strong>of</strong>advice and care <strong>of</strong> <strong>patients</strong> <strong>with</strong> AKI in our hospitals, asemphasised in the NCEPOD report from 2009. 8Predicting workforce requirements is challenging at thetime <strong>of</strong> writing because <strong>of</strong> uncertainty about the impact<strong>of</strong> changing practice (eg increasing use <strong>of</strong> specialistnurses) and changes in the detection and referral <strong>of</strong><strong>patients</strong> <strong>with</strong> CKD to renal units and the increasinginvolvement <strong>of</strong> the specialty in improving the provisionand quality <strong>of</strong> care <strong>of</strong> <strong>patients</strong> <strong>with</strong> AKI. A repeat census<strong>of</strong> all UK renal units and review <strong>of</strong> the estimate <strong>of</strong> therequired ratio <strong>of</strong> renal <strong>physicians</strong> to numbers <strong>of</strong> <strong>patients</strong>on RRT are in progress.9 Key points for commissioners1 Chronic kidney disease <strong>of</strong>ten coexists <strong>with</strong> otherchronic diseases, especially diabetes mellitus andcardiovascular diseases.2 Although <strong>patients</strong> <strong>with</strong> established renal failurecan be kept alive by dialysis or kidneytransplantation, mortality rates are as high as forsome malignant diseases: well-defined carepathways for end-<strong>of</strong>-life care are an important part<strong>of</strong> kidney services.3 There is a need for seamless commissioning <strong>of</strong> thewhole patient pathway, from early chronic kidneydisease right through to treatment by renalreplacement therapy and end-<strong>of</strong>-life care.4 For <strong>patients</strong> <strong>with</strong>out major comorbidity, kidneytransplantation <strong>of</strong>fers the best survival and quality<strong>of</strong> life: pre-emptive kidney transplantation from aliving kidney donor is optimal.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 221


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>5 Funding for additional treatment to allow <strong>patients</strong>to undergo ABO- and HLA-incompatibletransplantation will generate cost savings <strong>with</strong>intwo to three years but not <strong>with</strong>in the same financialyear.6 Variations in the use <strong>of</strong> home haemodialysis andperitoneal dialysis, and <strong>of</strong> maximal conservativecare for <strong>patients</strong> <strong>with</strong> significant comorbidity,appear to be driven more by clinicians’ preferencesand biases than by those <strong>of</strong> <strong>patients</strong>; promotion <strong>of</strong>shared decision-making will likely reduce thisvariation, as will the provision <strong>of</strong> formalmultidisciplinary clinics for <strong>patients</strong> approachingestablished renal failure.7 The UK Renal Registry provides high-qualitypr<strong>of</strong>essionally led audits <strong>of</strong> the quality <strong>of</strong> care <strong>of</strong><strong>patients</strong> <strong>with</strong> established renal failure, and isdeveloping plans to extend its work to <strong>patients</strong> <strong>with</strong>acute kidney injury, advanced kidney disease, andconservative care: it is also piloting measurement <strong>of</strong>the quality <strong>of</strong> shared decision-making, quality <strong>of</strong>life, and patient experience. Dissatisfaction <strong>with</strong>transport for dialysis is one <strong>of</strong> the most frequentcauses <strong>of</strong> poor experience.8 Managed renal networks have played an importantrole in promoting high-quality care. There is aparticular need to define clear clinical pathways forthe management <strong>of</strong> <strong>patients</strong> developing acutekidney injury in hospitals <strong>with</strong>out an on-site renalservice.9 There are major opportunities for reducing bothfiscal cost and the carbon footprint <strong>of</strong> kidney care,for instance by development <strong>of</strong> phone clinics andvirtual consultations between GPs andnephrologists. The current ‘payment by activity’funding arrangements provide a disincentive tosuch new pathways.10 The ratio <strong>of</strong> new to follow-up outpatient visits willnecessarily be lower than for many specialties dueto the large number <strong>of</strong> <strong>patients</strong> <strong>with</strong> chronicdisease (including those on dialysis and those <strong>with</strong>functioning kidney transplants) who requireregular specialist follow-up.References1 Gilg J, Castledine C, Fogarty D. UK Renal Registry 14thAnnual Report: Chapter 1. UK RRT incidence in 2010:national and centre-specific analyses. Nephron Clin Pract2012;120(suppl 1):c1–27.2 Castledine C, Casula A, Fogarty D. UK Renal Registry14th Annual Report: Chapter 2. UK RRT prevalence in2010: national and centre-specific analyses. Nephron ClinPract 2012;120(suppl 1):c29–54.3 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Chronic kidney disease inadults: UK guidelines for identification, management andreferral. London: RCP, 2006.4 National Institute for Health and Care Excellence. Earlyidentification and management <strong>of</strong> chronic kidney disease inadults in primary and secondary care. London: NICE,2010. www.nice.org.uk/CG73 [Accessed 25 April 2013].5 Renal Association. Renal patient view. London: RenalAssociation, 2010. www.renal.org/rpv [Accessed 25 April2013].6 Winearls CG, Fluck R, Mitchell DC, et al. Theorganisation and delivery <strong>of</strong> the vascular access service formaintenance haemodialysis <strong>patients</strong>. Report<strong>of</strong>ajoint<strong>working</strong> party. London: Renal Association, VascularSociety <strong>of</strong> Great Britain and Ireland and British Society<strong>of</strong> Interventional Radiology, 2006.7 Figueiredo A, Goh BL, Jenkins S, et al. Clinical practiceguidelines for peritoneal access. Perit Dial Int2010;30:424–9.8 National Confidential Enquiry into Patient Outcome andDeath. Acute kidney injury: adding insult to injury.London: NCEPOD, 2009. www.ncepod.org.uk/2009aki.htm [Accessed 25 April 2013].9 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK.Census <strong>of</strong> consultant <strong>physicians</strong> and medical registrars inthe UK, 2011: data and commentary. London: RCP,2013.10 Department <strong>of</strong> Health. National service framework forrenal services: part one – dialysis and transplantation.London: DH, 2004. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/Renal/DH 4102636 [Accessed 25April 2013].11 Department <strong>of</strong> Health. National service framework forrenal services: part two – chronic kidney disease, acute renalfailure and end <strong>of</strong> life care. London: DH, 2006. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/Renal/DH 4102636 [Accessed 25 April 2013].12 Renal Association. Clinical practice guidelines committee.Petersfield: Renal Association, 2010. www.renal.org/Clinical/GuidelinesSection/Guidelines.aspx [Accessed 25April 2013].13 Department <strong>of</strong> Health. Main renal unit. Health BuildingNote 07-02. London: Stationery Office, 2008.14 Department <strong>of</strong> Health. Good practice guidelines for renaldialysis/transplantation units: prevention and control <strong>of</strong>blood-borne virus infection. Recommendations <strong>of</strong> a<strong>working</strong> group convened by the Public Health LaboratoryService (PHLS) on behalf <strong>of</strong> the DH. London: DH, 2002.15 British Transplantation Society and the RenalAssociation. United Kingdom guidelines for living donor222 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Renal medicinekidney transplantation, 3rd edition. London: BTS andRA, 2011.16 National Institute for Health and Care Excellence. Renalfailure – home versus hospital haemodialysis. Technologyappraisal TA48. London: NICE, 2002.www.nice.org.uk/TA48 [Accessed 25 April 2013].17 National Institute for Health and Care Excellence.Central venous catheters – ultrasound locating devices.Technology appraisal TA49. London: NICE, 2002.www.nice.org.uk/TA49 [Accessed 25 April 2013].18 National Institute for Health and Care Excellence. Renaltransplantation – immuno-suppressive regimens (adults).Technical appraisal TA85. London: NICE, 2004.www.nice.org.uk/TA85 [Accessed 25 April 2013].19 National Institute for Health and Care Excellence. Type 2diabetes: the management <strong>of</strong> type 2 diabetes (update).CG87. London: NICE, 2010. www.nice.org.uk/CG66 [Accessed 25 April 2013].20 National Institute for Health and Care Excellence. Renaltransplantation – immunosuppressive regimens forchildren and adolescents. Technology appraisal TA099.London: NICE, 2006. www.nice.org.uk/TA099 [Accessed25 April 2013].21 National Institute for Health and Care Excellence.Laparoscopic insertion <strong>of</strong> peritoneal dialysis catheters.Interventional procedures guidance 208. London: NICE,2007. www.nice.org.uk/guidance/IPG208 [Accessed 25April 2013].22 National Institute for Health and Care Excellence.Cinacalcet for the treatment <strong>of</strong> secondaryhyperparathyroidism in <strong>patients</strong> <strong>with</strong> end-stage renaldisease on maintenance dialysis therapy. Technologyappraisal TA117. London: NICE, 2007.www.nice.org.uk/TA117 [Accessed 25 April 2013].23 National Institute for Health and Care Excellence. Type 2diabetes: the management <strong>of</strong> type 2 diabetes [CG87: partialupdate <strong>of</strong> CG66]. London: NICE, 2009.www.nice.org.uk/CG87 [Accessed 25 April 2013].24 National Institute for Health and Care Excellence.Peritoneal dialysis: peritoneal dialysis in the treatment <strong>of</strong>stage 5 chronic kidney disease. London: NICE, 2011.www.nice.org.uk/CG125 [Accessed 25 April 2013].25 National Institute for Health and Care Excellence.Chronic kidney disease. London: NICE, 2011.www.nice.org.uk/QS5 [Accessed 25 April 2013].26 National Institute for Health and Care Excellence.Anaemia management in people <strong>with</strong> chronic kidneydisease. London: NICE, 2011. www.nice.org.uk/CG114[Accessed 25 April 2013].27 National Institute for Health and Care Excellence.Percutaneous transluminal radi<strong>of</strong>requency sympatheticdenervation <strong>of</strong> the renal artery for resistant hypertension.Interventional procedures guidance. London: NICE,2012. www.nice.org.uk/IPG418 [Accessed 25 April2013].28 National Institute for Health and Care Excellence.Hyperphosphataemia in chronic kidney disease:Management <strong>of</strong> hyperphosphataemia in <strong>patients</strong> <strong>with</strong> stage4 or 5 chronic kidney disease. London: NICE, 2013.www.nice.org.uk/CG157 [Accessed 25 April 2013].29 National Institute for Health and Care Excellence. Acutekidney injury: prevention, detection and management <strong>of</strong>acute kidney injury up to the point <strong>of</strong> renal replacementtherapy. London: Nice, 2013 [In press].http://guidance.nice.org.uk/CG/Wave24/1030 Department <strong>of</strong> Health. Renal specific management <strong>of</strong>medicines. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 408206131 Department <strong>of</strong> Health. Reducing MRSA and otherhealthcare associated infections in renal medicine. London:DH, 2007. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareacquiredinfection/Healthcareacquiredgeneralinformation/DH 06314432 RCP and Renal Association. The changing face <strong>of</strong> renalmedicine in the UK. The future <strong>of</strong> the specialty. Report <strong>of</strong> a<strong>working</strong> party. London: RCP, 2007.33 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. <strong>Consultant</strong> <strong>physicians</strong><strong>working</strong> <strong>with</strong> <strong>patients</strong>, 3rd edn. London: RCP,2003.34 Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians. Census <strong>of</strong>consultant <strong>physicians</strong> in the UK, 2006: data andcommentary. London: RCP, 2007.35 British Renal Society. A multi-pr<strong>of</strong>essional renal workforceplan for adults and children <strong>with</strong> renal disease.Recommendations <strong>of</strong> the National Renal WorkforcePlanning Group. Woking: BRS, 2002. www.britishrenal.org/Workforce-Planning/2002-Previous-Work.aspx[Accessed 25 April 2013].C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 223


2 Specialties Respiratory medicineRespiratory medicineDr Lisa Davies BMBCh FRCP <strong>Consultant</strong> respiratory physician1 Description <strong>of</strong> the specialtyWho are the <strong>patients</strong>?Respiratory medicine is a varied, exciting andchallenging specialty. It is concerned <strong>with</strong> the diagnosis,treatment and continuing care <strong>of</strong> children and adults <strong>of</strong>allages<strong>with</strong>awiderange<strong>of</strong>morethan30respiratoryand related conditions.Main disease patternsThe second edition <strong>of</strong> Burden <strong>of</strong> lung disease 1emphasised the immense and growing health andeconomic burden <strong>of</strong> respiratory illness in the UK. ADepartment <strong>of</strong> Health (DH) review showed that thetotal spend on respiratory care in 2008–9 was£4,247,325,000. 2 Respiratory diseases kill one in fivepeople – more than ischaemic heart disease. Nearly30,000 people die <strong>of</strong> chronic obstructive pulmonarydisease (COPD) every year, and lung cancer kills morewomen than breast cancer. Respiratory conditions arethe most commonly reported long-term illness in babiesand children, up to one in five adults consult a GP for arespiratory complaint annually, and respiratory diseaseis the second most common illness responsible foremergency hospital admission, <strong>with</strong> cases <strong>of</strong> COPDtaking up more than one million bed days in Englandalone.Disease areas include: airway diseases:– nasal, upper and middle airway problems– asthma and other small airway conditions– COPD sleep-disordered breathing diffuse parenchymal lung disease (DPLD) andsystemic diseases that affect the lung:– inflammatory and scarring lung conditions– sarcoidosis– pulmonary manifestations <strong>of</strong> systemic diseasesand drugs pleural conditions:– malignancy– pleural effusion– pneumothorax– conditions <strong>of</strong> the chest wall, thoracic spine anddiaphragm occupational lung disease allergic lung and bronchial disorders infection:– cystic fibrosis– bronchiectasis– tuberculosis (TB)– pneumonia and empyema– infective and non-infective pulmonary disordersin immunocompromised hosts critical care and lung failure (acute and chronic) pulmonary vascular diseases:– pulmonary hypertension– pulmonary haemorrhage– pulmonary embolism lung cancer and mesothelioma genetic and developmental lung disorders paediatric lung diseases end-<strong>of</strong>-life care for malignant and non-malignantlung conditions public health:– smoking cessation and tobacco and nicotineaddiction policy– epidemiology and prevention.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceThe typical service provides many components thatcontribute to respiratory care delivered over whole-carepathways, including care at home, in the communityandinhospital.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 225


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Primary care and community models<strong>of</strong> careThe British Thoracic Society (BTS) works closely <strong>with</strong>the main primary care pr<strong>of</strong>essional respiratory group,the Primary Care Respiratory Society (PCRS-UK), tocampaign for and plan delivery <strong>of</strong> expert integratedrespiratory care in the community through Improvingand Integrating Respiratory Services in the NHS(IMPRESS; www.impressresp.com), a joint initiative <strong>of</strong>the BTS and PCRS-UK. Many GPs provide chronic carefor <strong>patients</strong> <strong>with</strong> asthma and COPD, which is <strong>of</strong>tendelivered by practice nurses. A few GPs <strong>with</strong> a specialinterest (GPwSIs) in respiratory medicine have beenappointed. Respiratory medicine has been and remainsat the forefront <strong>of</strong> developing integrated services (seesection 7).Hospital-based careMost respiratory <strong>physicians</strong> continue to have a majorcommitment to the care <strong>of</strong> acutely ill medical <strong>patients</strong>in the emergency admission department. Respiratorydisease remains the second most common cause <strong>of</strong>emergency hospital admissions and, although the role<strong>of</strong> the acute physician is expanding in some acutemedical trusts <strong>with</strong> more <strong>of</strong> these specialists nowrunning medical admission units (MAUs), specialtyinput at the ‘front door’ and beyond must not becompromised. The national COPD audit <strong>of</strong> 2008 3found that only 53% <strong>of</strong> <strong>patients</strong> admitted <strong>with</strong> COPDexacerbations were under the care <strong>of</strong> a specialistrespiratory team. The care <strong>of</strong> these <strong>patients</strong> and otherrespiratory in<strong>patients</strong> <strong>with</strong> life-threatening conditions,such as acute asthma, severe pneumonia andpneumothorax, and the need to provide advice forin<strong>patients</strong> under the care <strong>of</strong> other medical andsurgical disciplines have a significant impact onworkload.Most outpatient referrals are from GPs, specialistcolleagues in the hospital and the emergencydepartment. Suspected cases <strong>of</strong> lung cancer and TBshould be seen <strong>with</strong>in 2 weeks, but facilities are alsoneeded to allow all other urgent referrals to be seenpromptly.Regional hospital carePatients <strong>with</strong> certain conditions, such as cystic fibrosis,are usually managed in regional centres and networks.Surgical and radiotherapy services and more complexbronchopleural medical interventions are usually basedin regional or subregional centres. Supra-regionalcentres exist for the assessment and management <strong>of</strong>occupational lung disease, pulmonary hypertension,complex assisted-ventilation needs and lungtransplantation.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong>Involving <strong>patients</strong> in decisions abouttheir treatmentIn 2009, the BTS established the Public LiaisonCommittee (PLC) to ensure that the society benefitsfrom access to informed and involved publicinvolvement in the planning and execution <strong>of</strong> all <strong>of</strong> itswork. Respiratory <strong>physicians</strong> are totally committedto these concepts and are aware <strong>of</strong> the crucialimportance <strong>of</strong> cultural and ethnic issues; discussionsand educational sessions on ethical matters takeplace regularly at educational meetings <strong>of</strong> theBTS.The care <strong>of</strong> <strong>patients</strong> <strong>with</strong> asthma and COPD providesexamples in which self-management plans have longbeen developed by respiratory <strong>physicians</strong> <strong>working</strong>jointly <strong>with</strong> Asthma UK and the British LungFoundation. A number <strong>of</strong> respiratory <strong>physicians</strong> arealso involved in the Health Foundation’s Co-creatingHealth initiative.Every respiratory clinic will have locally and nationallyproduced information leaflets available in differentlanguages. These are <strong>of</strong>ten provided by the BritishLung Foundation, Asthma UK and TB Alert, amongothers.Patients are <strong>of</strong>fered copies <strong>of</strong> letters to GPs andaccess to their medical records if requested.Respiratory <strong>physicians</strong> have developed trainingprogrammes and materials for breaking bad news tothose <strong>with</strong> cancer and other life-limiting lungconditions, which include the IMPRESS DVD Livingand dying <strong>with</strong> COPD.Patients <strong>with</strong> long-term conditions, <strong>patients</strong>upport groups and the role <strong>of</strong> the expertpatientThe specialty recognises the vital importance <strong>of</strong> apatient-centred service. Asthma, COPD, cystic fibrosis226 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Respiratory medicineand bronchiectasis are examples <strong>of</strong> chronic conditionsfor which care is shared <strong>with</strong> primary care. The BTS haslong supported the British Lung Foundation indeveloping Breathe Easy patient support groups and theCystic Fibrosis Trust in helping <strong>patients</strong> and families<strong>with</strong> cystic fibrosis.The concept <strong>of</strong> the expert patient is welcomed,especially to improve care for <strong>patients</strong> <strong>with</strong> chronicrespiratory conditions. The BTS greatly values the input<strong>of</strong> lay representatives on all <strong>of</strong> its committees and is<strong>working</strong> closely <strong>with</strong> the <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians’(RCP’s) patient and carer group.4 Interspecialty and interdisciplinaryliaisonMultidisciplinary team <strong>working</strong>Respiratory specialists have long worked as a team <strong>with</strong>career-grade doctors, doctors in training, ward-basedand outpatient nurses, and other allied healthcarepr<strong>of</strong>essionals committed to providing high-qualitypatient care, including: respiratory nurse specialists (RNSs) clinical respiratory physiologists clinical scientists physiotherapists psychologists secretaries managers.Examples in which these colleagues contributesubstantially include: specialist clinics smoking cessation advice and support early assisted discharge and pulmonaryrehabilitation services ambulatory and long-term domiciliary oxygen andnebuliser assessments acute and domiciliary non-invasive ventilation(NIV) service for <strong>patients</strong> <strong>with</strong> ventilatory failure sleep-related breathing disorders service, includingcontinuous positive airway pressure (CPAP) therapy providing education for <strong>patients</strong>, their carers, otherhealthcare pr<strong>of</strong>essionals and the wider community providing an invaluable counselling service for clinical respiratory physiologists, runningdiagnostic and therapeutic lung-functionservices.Working <strong>with</strong> other specialistsMembers <strong>of</strong> the respiratory team liaise <strong>with</strong> many otherspecialties, particularly <strong>with</strong> histopathology,microbiology, radiology, thoracic surgery, oncology,palliative medicine, public health and social services.Regular meetings <strong>with</strong> radiological and surgicalcolleagues to review scans and radiographs and todiscuss patient management are common. Close clinicalliaisons have been developed between respiratory<strong>physicians</strong> and colleagues from disciplines in whichmultisystem diseases affect the lungs. These includerheumatology, haematology, transplant services,genitourinary medicine, renal medicine and oncology.Respiratory teams increasingly are developingcollaborations <strong>with</strong> other specialists, particularlycardiologists, to provide high-quality care for the largenumber <strong>of</strong> respiratory <strong>patients</strong> who have multiplecomorbidities.Lung cancer is a good example <strong>of</strong> a disease in whichrespiratory <strong>physicians</strong> play a key role inmultidisciplinary teams (MDTs). Most respiratory<strong>physicians</strong> are heavily involved in the diagnosis andmanagement <strong>of</strong> <strong>patients</strong> <strong>with</strong> lung cancer. In 2007, therewere 177 lung cancer MDTs in the 30 cancer networksin England; about 85% <strong>of</strong> these were chaired byrespiratory <strong>physicians</strong>, as were most lung cancer-specificnetwork <strong>working</strong> groups. Other MDTs and networksare emerging for TB, DPLD, COPD and end-<strong>of</strong>-life care.5 Delivering a high-quality serviceWhat is a high-quality service?A high-quality service implies that all <strong>patients</strong> receiveprompt, expert, effective and compassionate care, and,<strong>with</strong> few exceptions, this should be available locally.This requires a well-motivated, well-staffed MDT thathas access to suitable facilities. Patients and otherpr<strong>of</strong>essionals should expect continual access to a localexpert respiratory advice service, so respiratory<strong>physicians</strong> should never be single-handed and <strong>working</strong>in isolation.Maintaining and improving the quality <strong>of</strong> careService developments to deliver improvedpatient careThe resources required for a district general hospital(DGH) to provide a high-quality service aresummarised in Table 1.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 227


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Resource requirementsSettingInpatient unitOutpatient servicesDiagnostic and therapeuticfacilitiesRequirementsFully staffed and efficient, <strong>with</strong> specialist respiratory wardsHDU or acute lung unit <strong>with</strong> continuous access to acute NIVEndoscopy unit for bronchoscopic and pleural investigationsEasy access to ultrasound for pleural proceduresFacilities for day-case investigation and careDedicated outpatient unit <strong>with</strong> natural lighting and <strong>of</strong> sufficient size for all members <strong>of</strong> theMDTQuiet room for the bereaved and to give bad news/counsellingSeminar room for unit meetings and MDTsLung-function service in each clinic, <strong>with</strong> support from a fully equipped lung-function laboratoryHigh-definition screens in each clinic room for access to PACS, and an efficient imagingdepartment in close proximityRelevant pharmacy serviceImmediately bookable slots for endoscopy and all imagingAdequate secretarial and clerical staff, who are familiar <strong>with</strong> running respiratory servicesFlexible appointment systemBronchoscopy suite <strong>with</strong> facilities for advanced diagnostic and therapeutic procedures(endobronchial ultrasound, stenting, laser therapy, etc)Fully equipped and staffed lung-function laboratory <strong>with</strong> facilities to perform routine andhighly specialised investigationsInvestigation, treatment and ongoing support <strong>of</strong> <strong>patients</strong> <strong>with</strong> sleep-related breathingdisorders, including secure funding for equipment for CPAP and ongoing technical and clinicalsupportFull polysomnography, dedicated sleep beds and soundpro<strong>of</strong>ed facilities for undertaking sleeptests in more specialist unitsAssessment <strong>of</strong> causes <strong>of</strong> alveolar hypoventilation (neuromuscular, obesity or pulmonary inorigin)Provision <strong>of</strong> domiciliary NIV, including clinical and technical supportAmbulatory and long-term oxygen and inhaled therapy assessment serviceFacilities and beds for the provision <strong>of</strong> expert end-<strong>of</strong>-life care by the respiratory physicianCPAP = continuous positive airway pressure; HDU = high-dependency unit; MDT = multidisciplinary team; NIV = non-invasive ventilation;PACS = picture archiving and communications system.Education, training, continuing pr<strong>of</strong>essionaldevelopment (CPD) and appraisalsThe BTS works closely <strong>with</strong> the specialist advisorycommittee (SAC) to set the training curriculum forrespiratory trainees, almost all <strong>of</strong> whom undertake bothrespiratory and general medical training. In 2011 theGeneral Medical Council (GMC) approved dualtraining in intensive care medicine and respiratorymedicine, and this is already proving popular. Regionaland national training directors ensure consistency <strong>of</strong>content, and out-<strong>of</strong>-programme experience isencouraged. Funded educational sessions are requiredfor respiratory trainers.The BTS provides information on its website thatsignposts doctors to material and resources on CPD andquality improvement initiatives, which those <strong>working</strong> inrespiratory medicine will find useful as they compiletheir supporting information portfolio for revalidation.Details are available at www.brit-thoracic.org.uk/Delivery-<strong>of</strong>-Respiratory-Care/Revalidation.aspxFurther information and support is is available onthe RCP’s website: www.rcplondon.ac.uk/cpd/revalidationThe Education Committee and the Science and ResearchCommittee <strong>of</strong> the BTS organise numerous short-coursetraining meetings on a wide range <strong>of</strong> subjects; theannual summer CPD meeting; and the winter science,audit and educational conference. Conference abstractsare published in a supplement in Thorax in Decembereach year. 4 Since 2011, the Society has also run businessleadership programmes, recognising the need for its228 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Respiratory medicinemembers to take on leadership roles to develop systems<strong>of</strong> respiratory care for local communities.Research – clinical studies and basic scienceThe specialty has an excellent track record forundertaking multicentre clinical research and continuesto encourage respiratory specialty trainees to take timeout <strong>of</strong> their training programmes to undertake researchprojects. With the changing research governance and tocorrect the long-term underfunding <strong>of</strong> both basic andclinical lung research, the UK Respiratory ResearchCollaborative (UKRRC) has been formed by the BTS,lung charities, research funding bodies and otherrespiratory pr<strong>of</strong>essional societies, to prioritise andfacilitate translational lung research and build researchcapacity. Research training fellowships have alreadybeen appointed. An active respiratory specialty group <strong>of</strong>the UK Clinical Research Network has been establishedto encourage and facilitate research.Specialty and national guidelinesThe BTS has been at the forefront <strong>of</strong> guidelineproduction for more than 25 years. Guidelines arewritten in accordance <strong>with</strong> the BTS’s manual forguideline production, and the BTS guidelineproduction process was awarded NICE accreditation in2011. The BTS guidelines are based on availableevidence and adhere to the AGREE criteria(www.agreetrust.org). They are regularly updated andare available to download free from the BTS website(www.brit-thoracic.org.uk). As part <strong>of</strong> the BTScommitment to drive service improvement andpromote excellent patient care, BTS quality standardswill be produced for each BTS guideline, to provide aconcise set <strong>of</strong> markers <strong>of</strong> good practice. The first BTSquality standards document for bronchiectasis waspublished in 2012. 5Quality tools and frameworks, including nationalclinical strategyThe BTS provides an excellent web-based audit toolsystem, which has recently been revised and updated.National audits by the BTS are included on the list forinclusion in Quality Accounts in England, approvedaudits and regular newsletters, and National AdvisoryGroup for Clinical Audit and Enquiries (NAGCAE), andan annual audit report can be downloaded from thewebsite. Different areas <strong>of</strong> practice are audited in acyclical fashion; areas covered in 2012 included adultand paediatric asthma, adult and paediatriccommunity-acquired pneumonia, adult NIV,emergency oxygen, COPD discharge and bronchiectasis(www.brit-thoracic.org.uk/audit.aspx). The BTS is amajor partner in the next national COPD audit whichwill run from 2013. This new national audit, which willbe coordinated by the RCP, builds on previousinfluential national audits <strong>of</strong> COPD and COPD peerreview (www.rcplondon.ac.uk/resources/nationalcopd-audit-programme-starting-2013).In addition,the BTS, jointly <strong>with</strong> the RCP, has undertakeninfluential national audits <strong>of</strong> COPD and COPDpeer-review learning exercises in collaboration <strong>with</strong> theHealth Foundation (National COPD Resources andOutcomes Project (NCROP)).An outcomes strategy for COPD and asthma in Englandwas published on 18 July 2011. This long-awaitedstrategy identified six objectives that will drive work totransform respiratory care: better prevention <strong>of</strong> COPD,reducing premature death from respiratory disease,improving quality <strong>of</strong> life, improving safe and effectivecare, reducing the impact <strong>of</strong> asthma, and reducinginequalities in access to and quality <strong>of</strong> services. 6 ANICEtechnology appraisal on CPAP for the treatment <strong>of</strong>obstructive sleep apnoea and hypopnea syndrome waspublished in 2008, 7 and the specialty was involved inupdating NICE’s COPD guidelines in 2010. 86 Clinical work <strong>of</strong> consultantsThis section includes an overview <strong>of</strong> clinicalprogrammed activities (PAs) required in respiratorymedicine for a nominal catchment population <strong>of</strong> aDGH <strong>of</strong> 250,000.Respiratory <strong>physicians</strong> have responsibilities for therespiratory health <strong>of</strong> the local population, as well as theindividual patient. Clinical PAs therefore need to use theknowledge and skills <strong>of</strong> hospital clinicians to servepopulations, as well as the <strong>patients</strong> referred to them.Models by which clinical leadership is included in jobplans and funded by commissioners already exist, andthere is an increasing need for respiratory leadershiproles to be formally recognised as clinical activities(sometimes referred to as knowledge and networkmanagement according to Right Care definitions). Thiswork may account for 1–2 PAs <strong>of</strong> a lead consultant’sworkload.Inpatient work<strong>Consultant</strong>s usually undertake at least twospecialty-based ward rounds per week (2 PAs). Eachward round generates its own share <strong>of</strong> additionalC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 229


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>administrative duties, including discharge-planningmeetings, meetings <strong>with</strong> relatives and dischargesummaries (0.5–1 PA).Daily specialist visits are becoming increasinglynecessary because <strong>of</strong> the need for urgent specialistadvice to be available consistently to MAUs to enablerapid turnover and triage and to support medicalhigh-dependency units (HDUs). This is likely to involveeach consultant in an additional 0.5 PA per week.In addition, most respiratory <strong>physicians</strong> have a majorcommitment to acute general medicine. Duties includeward rounds to review <strong>patients</strong> on the day <strong>of</strong> admission(at least twice daily) and usually a ward round the nextmorning to review <strong>patients</strong> who have been admittedovernight. This may require one further PA in additionto on-call PAs.Each consultant team should have no more than 20–25in<strong>patients</strong> under their care at any one time, includingwhen cross-cover is needed for leave. Respiratory wards<strong>of</strong>ten manage <strong>patients</strong> <strong>with</strong> a high need for expertmonitoring, management and consultant input,including those stepped down from the intensivetreatment unit (ITU). The maximum inpatient load forconsultants should be halved when such <strong>patients</strong> areincluded. A DGH <strong>of</strong> this size typically generates10 ward referrals per week to respiratory medicine fromother specialties, and 0.5–1 PA needs to be set aside forthis.Respiratory <strong>physicians</strong> who attend weekly meetings <strong>of</strong>the MDT require 0.5 PAs, and those <strong>with</strong> specific servicelinks (such as <strong>with</strong> critical care and thoracic surgeonson a transplantation service) will need pro-ratarecognition <strong>of</strong> PAs in their job plan.Outpatient workA DGH serving a population <strong>of</strong> 250,000 people typicallygenerates 900 new non-cancer respiratory referrals peryear. On the basis <strong>of</strong> consultants seeing 2–4 follow-up<strong>patients</strong> for every new patient (the trend recently istowards the lower figure), the number <strong>of</strong> consultantclinic sessions available per year and the time for patientadministration to support the clinic, a total <strong>of</strong> 11–12PAs per respiratory department is required forrespiratory clinics.In addition, consultants may need to follow up about10–16 general medicine <strong>patients</strong> per week as theircontribution to the acute take and the general medicalservice. Most consultants only have time in their jobplan to <strong>of</strong>fer two (to three) outpatient clinics a week(1 PA each) for specialty referrals, general medicalreferrals and follow-up appointments.New <strong>patients</strong> should be allocated 30 minutes forconsultant appointments and follow-up <strong>patients</strong>15 minutes (longer if trainees, medical students ornurse-led clinics are <strong>working</strong> alongside the consultantand for <strong>patients</strong> <strong>with</strong> complex respiratory problems).Based on a 4-hour clinic, a maximum <strong>of</strong> four new andeight follow-up <strong>patients</strong> can be seen per consultant.Experienced trainees (such as specialist registrars(StRs)), associate specialists and experienced staff-gradedoctors should see fewer <strong>patients</strong>. More junior traineesat foundation year 2 (F2) or core medical training(CMT) grade should attend the clinic for training andshould not be allocated extra <strong>patients</strong>.Specialist investigative and therapeuticprocedure servicesBronchoscopyMost respiratory <strong>physicians</strong> undertake onebronchoscopy session each week (1 PA), which shouldaccommodate no more than six bronchoscopies andfewer if complex procedures such as transbronchialbiopsy, pleural biopsy or drainage are added or if juniordoctors are being trained.Medical thoracoscopyThis service is growing in usefulness as it can increasediagnostic yield and reduce thoracic surgical workload,but it is demanding and requires an additional 0.5–1 PAper week, <strong>with</strong> 2 <strong>patients</strong> per session.Sleep-related breathing disordersThis is a rapidly developing area that has beenhighlighted by the publication <strong>of</strong> the National Institutefor Health and Care Excellence’s (NICE’s) technologyappraisal <strong>of</strong> CPAP. 7 Growth is likely to continue for theforeseeable future, as best estimates suggest that nomore than one in four <strong>patients</strong> <strong>with</strong> symptomaticobstructive sleep apnoea/hypopnoea syndrome(OSAHS) in the UK has so far been identified. A sleepservice will require anything from 1 PA to 7 PAs perweek, depending on the complexity <strong>of</strong> the service andthe number <strong>of</strong> <strong>patients</strong>. As a guideline, an averagedepartment in a DGH that serves a population <strong>of</strong> about500,000 and that has about 500 new referrals perannum, 200 new <strong>patients</strong> on CPAP per annum and a230 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Respiratory medicinecumulative follow-up population <strong>of</strong> 1,500 on long-termCPAP is likely to need: consultant medical staff (5–8 PAs) nursing, scientific and technical staff (3–4whole-time equivalents (WTEs)) secretarial and clerical staff (1 WTE).Ward NIV for acute respiratory failure (due toexacerbations <strong>of</strong> COPD)This service must be available in all hospitals andshould be led by a respiratory consultant. In mosthospitals, one lead consultant supervises the serviceand, depending on the number <strong>of</strong> <strong>patients</strong> who requireNIV, would require 1–2 PAs.Domiciliary assisted-ventilation serviceWith the introduction <strong>of</strong> domiciliary NIV for <strong>patients</strong><strong>with</strong> COPD, in addition to <strong>patients</strong> <strong>with</strong> neuromusculardisorders and morbid obesity, it is likely that thesessional commitment required for this respiratoryservice will increase significantly. As a starting guide,1 PA should be allocated to run the domiciliary servicefor every 50 <strong>patients</strong>, including 10 new <strong>patients</strong> per year.Pulmonary rehabilitation servicePulmonary rehabilitation is a highly effective service.It is provided largely by an MDT, including RNSs andphysiotherapists, <strong>with</strong> dietitians, occupationaltherapists, social services, pharmacists and otherhealthcare pr<strong>of</strong>essionals having sessional inputs. Thelead supervising clinician may need to allocate 0.5 PAper week for this – or more if the consultant also takessome <strong>of</strong> the educational sessions or pre-assessmentclinics.Specialist on callUnfortunately, very few DGHs are able to providecontinuous specialist advice from on-call consultant<strong>physicians</strong> in respiratory medicine, although specialistadvice is usually available.Other specialist activities, including activitiesbeyond the local servicesExamples <strong>of</strong> specialist services provided at a local levelinclude the following: Lung cancer: most respiratory <strong>physicians</strong> manage<strong>patients</strong> <strong>with</strong> lung cancer as part <strong>of</strong> their normal jobplan, but those who attend meetings <strong>of</strong> the MDTrequire 0.5 PA per week for this and at least another0.5 PA is needed for the local lead lung-cancerphysician who coordinates services. Delivery <strong>of</strong> therelevant quality standards for the respiratorymedicine department <strong>of</strong> a DGH <strong>with</strong> averagestandardised mortality ratio for lung cancer requires10 PAs. Critical care involvement: respiratory <strong>physicians</strong> areincreasingly involved in the very time-demandingsupervision <strong>of</strong> HDUs and the provision <strong>of</strong> NIVrespiratory support outside ITUs. TB services: in most trusts, <strong>patients</strong> <strong>with</strong> bothpulmonary and non-pulmonary TB are managed byone or two named respiratory consultants. Oneconsultant takes the lead for the service, includingtracing contacts, managing difficult andmultidrug-resistant cases, and coordinating the localTB service network. The lead clinician requiresdedicated PAs for this based on the number <strong>of</strong> localcases: 0.5 PA per week for 25 TB cases annually, 1 PAfor 50 cases annually and pro rata for increasingnumbers, as long as they are adequately supportedby TB RNSs (1 WTE per 50 cases) andadministrative support. Specialist clinics: many consultants <strong>of</strong>fer dedicatedclinics for <strong>patients</strong> <strong>with</strong>, for example, difficultasthma, DPLD and bronchiectasis. If such clinics arein addition to their usual two to three clinics perweek, an extra PA is needed per clinic.Examples <strong>of</strong> specialist service provision for specifiedconditions at a regional or supra-regional level areshown below: Cystic fibrosis: the care <strong>of</strong> <strong>patients</strong> <strong>with</strong> cystic fibrosisis normally managed by large regional centres. TheCystic Fibrosis Trust recommends0.75 WTE <strong>of</strong> specialist consultant grade time per50 <strong>patients</strong> under full care, supported by a full range<strong>of</strong> supporting staff, including non-consultant careergrade (NCCG) doctors. 9 A respiratory physician<strong>with</strong> appropriate expertise may provide local care to<strong>patients</strong> <strong>with</strong> cystic fibrosis as the spoke <strong>of</strong> ahub-and-spoke model, <strong>with</strong> a large regional centreas the hub; that physician will require half <strong>of</strong> the PAallocation stated above, based pro rata on thenumber <strong>of</strong> cases. Lung transplantation: the five lung transplantationcentres are based in Birmingham, Harefield,Manchester, Newcastle and Papworth. Each centrerequires consultant <strong>physicians</strong> who specialise in theassessment and management <strong>of</strong> <strong>patients</strong> aftertransplantation. At least 5 PAs per week arenecessary.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 231


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> Pulmonary vascular disease: thisisorganisedonasupra-regional basis, and all seven centres (six inEngland and one in Scotland) have been approvedby the National Specialist Commissioning AdvisoryGroup (NSCAG) or National Services Division(NSD) in Scotland. All centres have at least twoconsultants trained in pulmonary vascular diseasewhowillbeabletocommitupto50%<strong>of</strong>theirtimeto the specialty. Occupational lung diseases: consultants who work insuch units will receive many tertiary referrals andwill require at least 3–5 PAs per week for thiscomplex work.7 Opportunities for integratedrespiratory careAlthough respiratory medicine provides a mainlyhospital-based service, job patterns involvingcommunity work are increasingly being developed, andconsultants in integrated respiratory care, who havesessions both <strong>with</strong>in a hospital and in the widercommunity, have been appointed in some areas.Examples <strong>of</strong> community work include: development <strong>of</strong> care pathways to facilitate care closerto home clinical leadership for integrated respiratory careservices to ensure excellent multidisciplinary clinicalcare across the whole pathway leading local respiratory networks education <strong>of</strong> primary and intermediate carehealthcare pr<strong>of</strong>essionals medical input into pulmonary rehabilitation,respiratory nursing services and hospital-at-homeand outreach services clinics in a non-hospital-based setting clinical responsibility for high-quality lung functionand oxygen assessment services assessing and managing <strong>patients</strong> <strong>with</strong> complexbreathlessness in the community promotion <strong>of</strong> better end-<strong>of</strong>-life care for those <strong>with</strong>severe lung disease.8 Workforce requirements forthe specialtyTo provide a high-quality, patient-centred, specialistrespiratory service, as described above, a DGH thatserves a population <strong>of</strong> 250,000 people requires 7 WTEadult respiratory <strong>physicians</strong>, equating to 1,428 WTEs inEngland. This assumes that they also undertake on-callwork, are adequately supported by a team <strong>of</strong> otherrespiratory pr<strong>of</strong>essionals, have adequate facilities andresources, and work under a direct clinical contract <strong>of</strong>7.5PAs.Manyunitsfallwellshort<strong>of</strong>thisnumber.Withdemands for a consultant-led and -delivered service,pressures from the European Working Time Directive,an ageing population and the changing <strong>working</strong>patterns <strong>of</strong> consultants (<strong>with</strong> more opting to work lessthan full time), it is estimated that 1.4 consultants willbe required to replace every one current WTE in futureyears.In November 2012, 976 consultants were <strong>working</strong> inrespiratory medicine in England and, despite financialpressures, the numbers <strong>of</strong> respiratory consultants hascontinued to increase. In the last quarter <strong>of</strong> 2012 therewere 641 respiratory trainees in England, roughly half <strong>of</strong>whom are female; 104 <strong>of</strong> these trainees were out <strong>of</strong>programme (OOP) at that time. Training programmedirectors and others continue to actively support OOPactivity, but it is increasingly difficult to fill gaps thatthen remain in training programmes <strong>with</strong> LAT (locumappointment – training) doctors (only 12% <strong>of</strong>respiratory LAT posts were filled in 2012). In contrast tosome other specialties, <strong>with</strong> the feminisation <strong>of</strong> theworkforce, there has been little increase in thenumbers <strong>of</strong> trainees or consultants <strong>working</strong> less thanfull time.Respiratory <strong>physicians</strong> who responded to the RCP’scensus in September 2011 were contracted for anaverage <strong>of</strong> 10.8 PAs, but worked an average <strong>of</strong> 12 PAs perweek, the vast majority <strong>of</strong> which were clinical. 10 Withchanges in <strong>working</strong> patterns and the move toconsultant-delivered service, it seems that consultantexpansion needs to continue for several years to come,albeit at a slower rate than we have seen in recentyears.9 <strong>Consultant</strong> work programme/specimenjob planThe 10-PA job plan shown in Table 2 assumes that thecorrect number <strong>of</strong> WTE consultants is employed in thedepartment. As respiratory services are delivered byteams, individualised job plans – in terms <strong>of</strong> bothcontent and number <strong>of</strong> PAs worked – can easily beadapted from the 10-PA job plan on a proportionalbasis to accommodate flexible <strong>working</strong>.232 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Respiratory medicineTable 2 <strong>Consultant</strong> work programme/specimen job planActivityDirect clinical careWorkloadProgrammed activities(PAs)Outpatient clinics 3Ward rounds20–25 <strong>patients</strong> maximum (half that number ifinvolving complex or high-care <strong>patients</strong>, such asITU step-down cases)2MDT meetings (eg lung cancer) 0.5Routine bronchoscopy, transbronchial lung biopsyand pleural proceduresBronchoscopy (6 per session) 1Specialist investigative/therapeutic procedures Lung or pleural biopsies (3 per session) 0–1Clinical lead activityWorkload examples are given in the text.Depending on the activity, some <strong>of</strong> this workmay fall under supporting pr<strong>of</strong>essional activities(see below)0–1Clinically related administration 1–2Specialist on-call and/or general medicalon-call/post-take ward roundsTotal number <strong>of</strong> direct clinical care PAsSupporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong>healthcareOther NHS responsibilitiesExternal dutiesMost respiratory <strong>physicians</strong> also undertakeacute and general medicineEducation and training, appraisal, departmentalmanagement and service development, auditand clinical governance, CPD and revalidation,researchFor example, medical director, clinical director,lead consultant in specialty, clinical tutorFor example, work for deaneries, royal colleges,specialist societies, Department <strong>of</strong> Health orother government bodies0.5–1.57.5 on average2.5 on averageLocal agreement <strong>with</strong>trustLocal agreement <strong>with</strong>trustCPD = continuing pr<strong>of</strong>essional development; DH = Department <strong>of</strong> Health; ITU = intensive treatment unit; MDT = multidisciplinary team meeting.10 Key points for commissionersCommissioning is considered to be the process <strong>of</strong>assessing the health needs <strong>of</strong> a population, and thenplanning, securing and monitoring the best possiblerange and quality <strong>of</strong> health services and healthimprovement services given the resources available. 111 High-quality respiratory commissioning enablesthedelivery<strong>of</strong>therightcareattherighttimeandin the right location for each individual patient<strong>with</strong> respiratory illness by a competent workforcethat intervenes <strong>with</strong> knowledge and understanding<strong>of</strong> the patient’s place on a local pathway <strong>of</strong>care.2 High-quality respiratory commissioning isinformed by accurate local information on theburden <strong>of</strong> respiratory disease and the impact onexisting services across the whole system <strong>of</strong>respiratory care.3 It is necessary to have a common understanding <strong>of</strong>existing local respiratory pathways and services andtheir interdependence, as well as accurateinformation on local respiratory outcomes,including distinguishing variation fromunwarranted variation.4 High-quality respiratory commissioning supportsthe development and implementation <strong>of</strong>‘currencies’ that encourage right care, eg carebundle tariffs and personalised care tariffs.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 233


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>5 Patients and carers should provide input into thedesign <strong>of</strong> local services.6 A culture must be developed that attributes valueto knowledge, expertise and sharing <strong>of</strong> learning.7 Current and future workforce planning andtraining must be a component <strong>of</strong> commissionedservices.8 High-quality respiratory commissioning deliversevidence-based, best-value care.9 Support to stop smoking, <strong>with</strong> counselling andpharmacotherapy as a treatment for smokers <strong>with</strong>respiratory problems, is essential across primary,secondary and intermediate care.10 Disease-specific examples <strong>of</strong> what high-qualityrespiratory commissioning might deliver(depending on local needs assessment) include:• earlier diagnosis <strong>of</strong> lung cancer and COPD• high-quality asthma care in the community,which reduces avoidable hospital admissions.Further informationThe national strategy for COPD in England 6 provides aframework for commissioners and COPDcommissioning guidance, and packs will be availablefrom NICE and the DH.A national clinical director (respiratory) was appointedto NHS England in April 2013. Respiratory medicine isrepresented on a number <strong>of</strong> Clinical Reference Groupsfor commissioning specialised services(www.england.nhs.uk/ourwork/d-com/spec-serv).References1 BritishThoracicSociety.Burden <strong>of</strong> lung disease, 2nd edn.A statistics report from the British Thoracic Society 2006.London: BTS, 2006. www.brit-thoracic.org.uk/Portals/0/Library/BTS%20Publications/burdeon <strong>of</strong> lungdisease2007.pdf2 Department <strong>of</strong> Health. Estimated England level grossexpenditure by programme budget. www.rightcare.nhs.uk/downloads/dh englandlevel 2008-09.pdf3 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Report <strong>of</strong> the national chronicobstructive pulmonary disease audit 2008: clinical audit <strong>of</strong>COPD exacerbations admitted to acute NHS units acrossthe UK. London: RCP, 2008. www.rcplondon.ac.uk/sites/default/files/report-<strong>of</strong>-the-national-copd-audit-2008-clinical-audit-<strong>of</strong>-copd-exacerbations-admitted-toacute-nhs-units-across-the-uk.pdf4 Abstracts <strong>of</strong> the winter meeting <strong>of</strong> the British ThoracicSociety, London,1–3 December 2010. Thorax 2010;65(suppl IV): A1–196.5 BritishThoracicSociety.Quality standards for clinicallysignificant bronchiectasis. London: BTS, 2012.www.brit-thoracic.org.uk/Guidelines/Bronchiectasis-Guideline-non-CF.aspx6 Department<strong>of</strong>Health.Anoutcomesstrategyforchronicobstructive pulmonary disease (COPD) and asthma inEngland. London: DH, 2011. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 1279747 National Institute for Health and Care Excellence.Continuous positive airway pressure for the treatment <strong>of</strong>obstructive sleep apnoea/hypopnoea syndrome.Technology appraisal TA139. London: NICE, 2008.www.nice.org.uk/guidance/index.jsp?action=download&o=400858 National Institute for Health and Care Excellence.Management <strong>of</strong> chronic obstructive pulmonary disease inadults in primary and secondary care (partial update).http://guidance.nice.org.uk/CG1019 Cystic Fibrosis Trust. Standards for the clinical care <strong>of</strong>children and adults <strong>with</strong> cystic fibrosis in the UK 2001.London: Cystic Fibrosis Trust, 2001. www.cftrust.org.uk/aboutcf/publications/consensusdoc/C 3000Standards <strong>of</strong> Care.pdf10 Federation <strong>of</strong> <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UnitedKingdom. Census <strong>of</strong> consultant <strong>physicians</strong> and medicalregistrars in the UK, 2011: data and commentary. London:RCP, 2013.11 Smith J, Curry N, Mays N, Dixon J. Where next forcommissioning in the English NHS? London: NuffieldTrust/The King’s Fund, 2010. www.nuffieldtrust.org/sites/files/nuffield/publication/where next forcommissioning in the english nhs 230310.pdf234 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties RheumatologyRheumatology ∗Dr Ian Rowe FRCP MA MD <strong>Consultant</strong> rheumatologistDr Neil Snowden FRCP <strong>Consultant</strong> rheumatologistDr Ruth Richmond FRCP <strong>Consultant</strong> rheumatologistDr Marwan Bukhari FRCP PhD <strong>Consultant</strong> rheumatologist1 Description <strong>of</strong> the specialtyRheumatology deals <strong>with</strong> the investigation, diagnosisand management <strong>of</strong> <strong>patients</strong> <strong>with</strong> arthritis and othermusculoskeletal conditions. This incorporates morethan 200 disorders affecting joints, bones, muscles ands<strong>of</strong>t tissues, including inflammatory arthritis and othersystemic autoimmune disorders, vasculitis, s<strong>of</strong>t-tissueconditions, spinal pain and metabolic bone disease. Asignificant number <strong>of</strong> musculoskeletal conditions alsoaffect other organ systems.Rheumatology is a multidisciplinary specialty and therheumatologist works in close liaison <strong>with</strong> othermedical specialists and healthcare pr<strong>of</strong>essionals.Accredited training for paediatric and adolescentrheumatology is based <strong>with</strong>in paediatrics, althoughadult rheumatologists should be aware <strong>of</strong> the spectrum<strong>of</strong> conditions that affect children in order to take part inthe transitional care <strong>of</strong> older adolescents and youngadults. Specific training is available in sports andrehabilitation medicine.Who are the <strong>patients</strong>?The burden <strong>of</strong> musculoskeletal disease in the UK issignificant (Table 1), <strong>with</strong> 10 million <strong>working</strong> days lostin 2006–7 due to musculoskeletal conditions, which issecond only to stress, depression and anxiety. 1 Theestimated cost to society is £5.7 billion per year.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralUp to 30% <strong>of</strong> people who consult their GPs and 40% <strong>of</strong>those who attend NHS walk-in centres do so <strong>with</strong> amusculoskeletal complaint. 10 Those <strong>with</strong> inflammatoryarthritis or autoimmune connective tissue diseaserequire input from a rheumatologist. Early referral for<strong>patients</strong> <strong>with</strong> inflammatory disease is vital to minimisejoint damage and is cost-effective. Treatment is mosteffective if started <strong>with</strong>in 3 months <strong>of</strong> symptom onset. 5Referral to secondary care via a rapid-access system isappropriate for <strong>patients</strong> <strong>with</strong> ‘red flags’, includingsystemic disorders such as malignancy or complexmultisystem disease. Most self-limitingnon-inflammatory disorders and exacerbations <strong>of</strong>chronic degenerative disease such as osteoarthritis andback pain are managed in primary care.The NHS white paper 11 for England will giverheumatologists more opportunities to work directly<strong>with</strong> frontline colleagues in primary care. Thecommissioning proposals should lead to improvedintegration <strong>with</strong> primary care and increased access tosupport and advice for GPs to manage musculoskeletaldisease in the community. Integral involvement <strong>of</strong>rheumatologists will ensure the appropriateformulation <strong>of</strong> quality and outcome measures in line<strong>with</strong> national standards and guidance.The Department <strong>of</strong> Health (DH) in England’s bestpractice guidance document The musculoskeletal servicesframework (MSF) 10 has emphasised the role <strong>of</strong> triage,assessment, diagnosis and treatment by practitioners<strong>with</strong> special interests (GPs, therapists and specialists)and the establishment <strong>of</strong> intermediate services betweenprimary and secondary care known as clinicalassessment and treatment services (CATS). The CATShave been proposed in order to improve the efficiencyand appropriateness <strong>of</strong> referrals. In order to besuccessful, the CATS must work in close liaison <strong>with</strong>rheumatologists and primary care specialists and shouldbe integrated <strong>with</strong> regard to continuing pr<strong>of</strong>essionaldevelopment (CPD) programmes, audit and teaching <strong>of</strong>specialist staff and students, rather than beingstand-alone entities.∗ Please see an appendix to this chapter, which has been written for the revised 5th edition 2013 (p. 249). The rest <strong>of</strong> the text has been reproduced fromthe 2011 edition.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 235


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Estimated numbers <strong>of</strong> people <strong>with</strong> rheumatic disease in the UKCondition Estimated number <strong>of</strong> people SourceAll musculoskeletal conditions 10 million people Arthritis Research UK 1Osteoarthritis-related joint pain 8.5 million National Institute for Health and CareExcellence 2Osteoporosis 2.1 million minimum European Vertebral Osteoporosis Study 3Back pain: GP consultations 2.6 million/year <strong>Royal</strong> <strong>College</strong> <strong>of</strong> General Practitioners 1991statistics applied to year 2000 population 4Rheumatoid arthritisIncidence 26,000/yearPrevalence 580,000National Audit Office, 2009 5Ankylosing spondylitis 200,000 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> General Practitioners 1991statistics applied to year 2000 population 4Systemic lupus erythematosus 10,000 Epidemiological survey in Leicester 6Scleroderma 1,500 Epidemiological survey in the West Midlands 7Gout 250,000 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> General Practitioners 1991statistics applied to year 2000 population 4Regional pain syndromes (eg shoulderpain)Chronic widespread pain(eg fibromyalgia)20% <strong>of</strong> adult population Epidemiological studies in north-west England(unpublished)11.2% <strong>of</strong> adult population Cr<strong>of</strong>t P, et al, 1993 8Juvenile idiopathic arthritis (JIA)Incidence: 10 per 100,000 (children upto 16 years)Estimated 12,000 children <strong>with</strong>JIA in UKSymmons DP, et al, 1996 9Secondary careThe core work <strong>of</strong> secondary care rheumatology servicesprovided by consultant rheumatologists and themultidisciplinary team (MDT) is the treatment <strong>of</strong>inflammatory arthritis, autoimmune connective tissuedisease and vasculitis. The availability <strong>of</strong> powerfulbiologic disease-modifying and immunosuppressivetreatmentshasmadeitpossibleforrheumatologyMDTs to develop care pathways <strong>with</strong> the aim <strong>of</strong>achieving clinical remission or very low disease activityfor <strong>patients</strong> <strong>with</strong> inflammatory arthritis. Theseaims are reflected in the recent NICE guidance forrheumatoid arthritis (http://guidance.nice.org.uk/CG79) and the National Audit Office’s report fromJuly 2009 on Services for people <strong>with</strong> rheumatoidarthritis. 5Tertiary careTertiary care can provide specialised services that coverthe needs <strong>of</strong> small groups <strong>of</strong> <strong>patients</strong> <strong>with</strong> rare orcomplex conditions, who may require specialisedinvestigation or management not available in a localhospital. Examples <strong>of</strong> these include complexautoimmune connective tissue diseases and raremetabolic bone diseases. These services may includespecialised surgery, such as neurosurgery and handsurgery, and specialist rheumatology MDTs includingrehabilitation therapists.Paediatric rheumatologyTertiary care services in paediatrics include specialistpaediatric and adolescent rheumatology services in allmajor children’s centres covering every region. Thesecentres provide outreach services that include <strong>working</strong><strong>with</strong> adult rheumatologists as part <strong>of</strong> a managed clinicalnetwork. It is good practice for adult rheumatologists toprovide paediatric rheumatology care <strong>with</strong>in localpaediatric services and <strong>with</strong>in a regional paediatricrheumatology network. 12236 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Rheumatology3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareWhat you do <strong>with</strong> <strong>patients</strong>Involving <strong>patients</strong> in decisions about theirtreatmentEvery patient should influence the delivery <strong>of</strong> care thatthey receive and good communication <strong>with</strong> all members<strong>of</strong> the rheumatology MDT is essential. <strong>Consultant</strong>sshould develop a personalised care plan <strong>with</strong> the patientto identify treatment and care. The white paper inEngland, Equity and excellence: liberating the NHS, 11promotes shared decision-making <strong>with</strong> <strong>patients</strong>: ‘nodecision about me <strong>with</strong>out me.’ This approachimproves compliance <strong>with</strong> therapy.Access to informationVoluntary and NHS organisations produce a wide range<strong>of</strong> patient literature on musculoskeletal conditions,together <strong>with</strong> related topics such as diet and exercise.Patients <strong>of</strong>ten refer to the internet for information andto hospital departments’ websites for guidance oncommon diseases and treatments, and details on how toaccess the MDT. Telephone advice lines are a standardpart <strong>of</strong> the service <strong>of</strong>fered by secondary caredepartments. Information should also be readilyavailable at GP surgeries. It is recommended that<strong>patients</strong> are given lay information regarding theircondition at the first consultation and are sent a copy <strong>of</strong>the clinic letters sent to their GP.Patient choice: cultural considerationsRheumatology departments should consider the specificneeds <strong>of</strong> their local population. For example: Literature is provided in appropriate languages andformats. Translators can be provided. Female <strong>patients</strong> can elect to be seen by a femaledoctor and chaperones. Services aim to allow <strong>patients</strong> to keep religiousfestivals and practices.Opportunities for educationArthritis Care <strong>of</strong>fers a range <strong>of</strong> courses such as‘Challenging arthritis’, which promotes independenceand was used by the DH as a model for their ExpertPatient Programme. Personal development courses,courses specifically aimed at young people and anarthritis awareness course for employers are alsoavailable.Table 2 Useful organisationsOrganisationArthritis CareArthritis andMusculoskeletal Alliance(ARMA)Arthritis Research UKBritish Sjogren’sSyndrome AssociationBritish Society forPaediatric and AdolescentRheumatology (BSPAR)British Society forRheumatology (BSR)Carers UKExpert Patient ProgrammeLupus UKMyositis AssociationNational Institute forHealth and CareExcellence (NICE)National OsteoporosisSocietyNational Patient SafetyAgencyNational RheumatoidArthritis SocietyPolymyalgia Rheumaticaand Giant Cell Arteritis UKReynaud’s andScleroderma AssociationScleroderma SocietyWebsite/email addresswww.arthritiscare.org.ukhelp@arthritiscare.org.ukwww.arma.uk.netwww.arthritisresearchuk.orgwww.bssa.uk.netwww.bspar.org.ukwww.rheumatology.org.ukwww.carersuk.org/Homewww.expert<strong>patients</strong>.co.ukwww.lupusuk.org.ukwww.myositis.orgwww.nice.org.ukwww.nos.org.ukwww.npsa.nhs.ukwww.rheumatoid.org.ukwww.pmrgcauk.comwww.raynauds.org.uk/www.sclerodermasociety.co.uk/newsite/index.phpPatient support groupsPeople <strong>with</strong> a chronic disease may experience otherphysical or psychological problems, eg fatigue anddepression, so rheumatology departments shouldprovide access to appropriate services, such asoccupational therapy, orthotics and clinical psychology.Voluntary sector organisations provide useful resources,membership schemes, information helplines andwebsites (Table 2). They also run specific informationand support services for young people.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 237


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>4 Interspecialty and interdisciplinary liaisonMultidisciplinary team <strong>working</strong>Rheumatologists have long advocated MDT <strong>working</strong>. 13This is embedded in the British Society forRheumatology (BSR)’s guidelines on the management<strong>of</strong> rheumatoid arthritis, 14 the Arthritis andMusculoskeletal Alliance (ARMA)’s standards <strong>of</strong> care 15and NICE clinical guideline CG79. 16<strong>Consultant</strong> rheumatologists are supported byrheumatology nurse practitioners, physiotherapists,occupational therapists, podiatrists, psychologists andorthotists. Nurse practitioners play a key role indelivering direct-access helplines, drug monitoring,rapid-access clinics, nurse prescribing, patienteducation and counselling. 17 Support regardingactivities <strong>of</strong> daily living and occupation for disabled<strong>patients</strong> is important, including provision <strong>of</strong>information on benefits agencies and liaison whereappropriate <strong>with</strong> community care agencies. Pharmacistshave a role to ensure patient safety, to help <strong>with</strong> drugmonitoring and to promote the introduction <strong>of</strong> newertreatments, eg biologic agents, through drug andtherapeutics committees. Pharmacy databases can alsoprovide units <strong>with</strong> data to assist audit.Working <strong>with</strong> other specialtiesCombined clinics provide an opportunity to coordinatecare for complex <strong>patients</strong> (eg <strong>with</strong> dermatology,respiratory and renal medicine), run dedicated clinicsfor paediatric and adolescent (transitional) <strong>patients</strong> andenable access to orthopaedic surgery. Specialist adviceshould be available throughout antenatal and postnatalcare for individuals <strong>with</strong> diseases such as lupus andantiphospholipid syndrome. It is also important toestablish good links <strong>with</strong> general orthopaedic, painmanagement and musculoskeletal radiology services,including dual-emission X-ray absorptiometry (DXA),magnetic resonance imaging (MRI) andmusculoskeletal ultrasound services.Working <strong>with</strong> GPs and GPs <strong>with</strong> a specialinterest (GPwSIs)The relationship <strong>of</strong> rheumatology units <strong>with</strong> primarycare is evolving rapidly, driven by the MSF 10 and thedevelopment <strong>of</strong> GP consortia in England. Trainingschemes for GPs <strong>of</strong>ten include rheumatology, and GPsmay join the MDT as clinical assistants. However,expansion <strong>of</strong> GPwSIs has led to the possibility <strong>of</strong>stand-alone community clinics, sometimes located<strong>with</strong>in the CATS. Unfortunately, collaboration betweenGPwSIs and rheumatology units has not always beenestablished, which causes concern about poorcoordination <strong>of</strong> care, quality, training and governance.The BSR has a curriculum <strong>with</strong> a competencyframework for GPwSIs. 18 Clinical governanceprocedures must be robust, and the BSR hasrecommended that GPwSIs work in close liaison <strong>with</strong>rheumatology units and take part in CPD. Similarprinciples apply to the development <strong>of</strong> new integratedrheumatology services.5 Delivering a high-quality serviceWhat is a high-quality service?High-quality rheumatology services should bepatient-centred, accessible and multidisciplinary(Tables 3–5): Enhancing quality <strong>of</strong> life (including preserving theability to remain in work) and ensuring people havea positive experience <strong>of</strong> their care are central aspects<strong>of</strong> a high-quality service. Access to the service must be equitable, prompt andphysically suited to those <strong>with</strong> disability. Care must be collaborative to allow integration andcontinuity across primary, intermediate, secondaryand (for some conditions) tertiary services. A strongMDT is pivotal for this.6 Clinical work <strong>of</strong> consultantsThe BSR recommends that no single-handed consultantrheumatologist should work in isolation or be expectedto provide an acute general medical service.Outpatient workRheumatology is an outpatient-based specialty.However, wide variation exists in the total number <strong>of</strong>clinics per consultant, which depends on the geography<strong>of</strong> the service, involvement in acute medicine, provision<strong>of</strong> community clinics, academic interests and otherduties including teaching and management.The expected workload is based on recommendations <strong>of</strong>best practice from the BSR. A full-time consultantrheumatologist would be expected to undertake 4–5clinics a week and those who perform general internalmedicine (GIM) 3–4 clinics a week. These wouldinclude routine clinics, special clinics (eg lupus clinicsand fracture prevention clinics) and combined clinics(eg <strong>with</strong> orthopaedic surgeons). Some consultants nowundertake musculoskeletal ultrasound and report onbone-density scans.238 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties RheumatologyTable 3 How to ensure that the service is <strong>of</strong> high qualityGuidelinesCommentsSpecialist society guidelinesThe BSR commissions and produces its own guidelines, which are available on thewebsite (www.rheumatology.org.uk) and in the journal Rheumatology.The BSR’s standards, guidelines and audit group keep guidelines up to date andcommission new guidelines and audit toolkits.NICE guidanceNICE has produced a number <strong>of</strong> appraisals and guidelines <strong>of</strong> importance torheumatology services (www.nice.org.uk/).Importantly, in February 2009, NICE published guidance on the management <strong>of</strong>rheumatoid arthritis in adults (http://guidance.nice.org.uk/CG79). 16 The documentemphasised the importance <strong>of</strong> early referral to a rheumatologist for <strong>patients</strong> <strong>with</strong>this common condition. It defined the need for close and regular monitoring <strong>of</strong><strong>patients</strong> <strong>with</strong> rheumatoid arthritis to enable tight control <strong>of</strong> disease activity usingdisease-modifying and biologic drugs.National Audit Office reportIn July 2009, the National Audit Office published the report Services for people <strong>with</strong>rheumatoid arthritis (www.nao.org.uk/publications/0809/services for people<strong>with</strong> rheum.aspx). 5 This supported the NICE guidelines and explained the long-termcost benefits <strong>of</strong> investing in these standards <strong>of</strong> care.ARMA standards <strong>of</strong> care projectARMA has produced a series <strong>of</strong> publications defining reasonable expectations <strong>of</strong> careand services for all people <strong>with</strong> musculoskeletal conditions; these are accompaniedby audit toolkits (www.arma.uk.net/).ARMA has recently published two documents Joint <strong>working</strong>? An audit <strong>of</strong> theDepartment <strong>of</strong> Health’s musculoskeletal services framework 19 (www.arma.uk.net/pdfs/MSF%20Review FINAL1.pdf) and The musculoskeletal map <strong>of</strong> England 20(www.arma.uk.net/pdfs/Musculoskeletal%20map%20FINAL%202.pdf). Thesedocuments highlight the significant variations in response to the MSF and in thequality <strong>of</strong> NHS musculoskeletal services across England.Inflammatory arthritis care pathwayIn 2009, the DH published a Commissioning pathway for inflammatory arthritis(www.nras.org.uk/includes/documents/cm docs/2010/i/ia pathway.pdf). 21 Thepathway encouraged commissioners and GPs to work <strong>with</strong> rheumatologists toredesign and deliver better services for <strong>patients</strong> <strong>with</strong> inflammatory arthritis.Peer reviewPeer review is a clinical governance tool that facilitates improvement in the quality<strong>of</strong> clinical service. The BSR promotes this and published new guidance 22(www.rheumatology.org.uk/includes/documents/cm docs/2010/p/2 peer reviewguidance 6 sept 2010.pdf) and a pr<strong>of</strong>orma 23 (www.rheumatology.org.uk/includes/documents/cm docs/2010/p/peer review pr<strong>of</strong>orma aug 2010.doc) for thescheme in 2010.The recommended workload is as follows: new <strong>patients</strong>: 6–7 new <strong>patients</strong> per clinic dependingon casemix, <strong>with</strong> one slot for urgent cases(approximately 30 minutes per patient) review clinics: 10–15 <strong>patients</strong> per clinic(10–15 minutes per patient) mixed clinics: one new patient takes the time <strong>of</strong> tworeview <strong>patients</strong>, but this depends on the casemix specialised clinics for <strong>patients</strong> <strong>with</strong> complexdisorders eg early rheumatoid arthritis, systemiclupus erythematosus, vasculitis and paediatricrheumatology: numbers <strong>of</strong> <strong>patients</strong> seen in clinicsneed to be reduced from recommendations above number <strong>of</strong> <strong>patients</strong> seen in consultant clinics needtobereducedfromrecommendationsaboveiftheconsultant is supporting and training junior staff (byabout 20%) number <strong>of</strong> <strong>patients</strong> seen in consultant clinics needtobereducedfromrecommendationsaboveiftheconsultant is undertaking undergraduate andpostgraduate teaching: the <strong>Royal</strong> <strong>College</strong> <strong>of</strong>Physicians (RCP) recommends a reduction <strong>of</strong> 25% number <strong>of</strong> <strong>patients</strong> seen in consultant clinicsneed to be reduced from recommendations above ifthe consultant is supervising nurse-ledclinics.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 239


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 4 Recent NICE, BSR and ARMA publications relevant to rheumatologyCompleted NICE musculoskeletalguidance 24 Current BSR guidelines 36 ARMA 53Rheumatoid arthritis 16Osteoarthritis 25Arthritis (juvenile idiopathic) –etanercept 26Osteoarthritis and rheumatoidarthritis – cyclooxygenase-2 (COX-2)inhibitors 27Psoriatic arthritis – etanercept,infliximab and adalimumab 28Rheumatoid arthritis – adalimumab,etanercept and infliximab 29Rheumatoid arthritis – certolizumabpegol 30Rheumatoid arthritis – drugs fortreatment after failure <strong>of</strong> a tumournecrosis factor (TNF) inhibitor 31Rheumatoid arthritis – tocilizumab 32Hyperuricaemia – febuxostat 33Osteoporosis – primary prevention 34Osteoporosis – secondaryGuidelines on safety <strong>of</strong> anti-TNFtherapies in RA 37Management <strong>of</strong> giant cell arteritis38Guidelines on eligibility criteria for thefirst biologic therapy in rheumatoidarthritis39Quick reference guide for monitoring<strong>of</strong> disease-modifying anti-rheumaticdrug (DMARD) therapy40Management <strong>of</strong> polymyalgiarheumatica41Management <strong>of</strong> rheumatoid arthritisafterfirst2years 42DMARD therapy 43Metoject44Management <strong>of</strong> adults <strong>with</strong>anti-neutrophil cytoplasmic antibody(ANCA)-associated vasculitis 45Management <strong>of</strong> gout46Management <strong>of</strong> rheumatoid arthritisprevention 35 (first 2 years)47Management <strong>of</strong> hot swollen joints inadults48Anti-TNF α therapy in psoriaticarthritis49Prescribing TNF blockers in adults <strong>with</strong>rheumatoid arthritis50Standards <strong>of</strong> care for persons <strong>with</strong>rheumatoid arthritis51Prescribing TNF α blockers in adults<strong>with</strong> ankylosing spondylitis 52Standards <strong>of</strong> careBack pain 54Inflammatory arthritis 55Osteoarthritis 56Connective tissue diseases 57Metabolic bone disease 58Regional musculoskeletal pain 59Overarching principles 60Musculoskeletal foot healthproblems 61Other publicationsJoint <strong>working</strong> 19The musculoskeletal map <strong>of</strong>England 20Charter for work for people affectedby musculoskeletal disorders in theUK 62Table 6 shows the patient allocation for non-consultantstaff.Casemix and ratio <strong>of</strong> new <strong>patients</strong> t<strong>of</strong>ollow-up <strong>patients</strong>The ratio <strong>of</strong> new <strong>patients</strong> to follow-up <strong>patients</strong> variesconsiderably, <strong>with</strong> a national mean <strong>of</strong> 1:3.9(interquartile range 1:1.3 to 1:7.8). 66 Anumber<strong>of</strong>variables are important, particularly casemix (which isinfluenced by the provision <strong>of</strong> local CATS and specialistservices) and the quality <strong>of</strong> GP services, including thecapacity for shared care. A casemix study from theMidlands identified that the major influence on theratio <strong>of</strong> new <strong>patients</strong> to follow-up <strong>patients</strong> was theproportion <strong>of</strong> <strong>patients</strong> <strong>with</strong> inflammatory conditions. 67Their mean ratio was 1:4.9, <strong>with</strong> a range <strong>of</strong> 1:3.0to 1:7.3.Primary care trusts (PCTs) in England tried to imposeratios for new <strong>patients</strong> to follow-up <strong>patients</strong> in anattempt to devolve follow-up care into the community.However, NICE guidelines on rheumatoid arthritisrecommend more frequent follow-up for <strong>patients</strong> <strong>with</strong>active disease, as well as rapid access and annual review.It is therefore important that rheumatology units areactively involved in discussions <strong>with</strong> PCTs and futureGP consortia (health boards in Wales) about developingappropriate care pathways and community services.Community servicesAn increasing number <strong>of</strong> consultant rheumatologistsare now <strong>working</strong> in community-based clinics, includingpolyclinics and CATS. Appropriate MDTs shouldprovide support at these peripheral sites. Furtherintegration <strong>with</strong> primary care services is likely in the240 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties RheumatologyTable 5 Maintaining and improving the quality <strong>of</strong> careActionService developmentsthat improve careLeadership role andthe introduction <strong>of</strong>service developmentsEducation andtrainingMentoring andappraisal <strong>of</strong> medicaland other pr<strong>of</strong>essionalstaffClinical governanceResearch – clinicalstudies and basicscienceLocal, regional andnational workCommentsRheumatology services operate a patient-centred model <strong>of</strong> care delivered in a multidisciplinarysetting.Service developments may be simple but <strong>with</strong> associated cost savings (eg introduction <strong>of</strong> nurse-ledclinics, telephone follow-up clinics or electronic advice to GPs) or may require significant planning andcapital investment (eg introduction <strong>of</strong> dedicated day units or building <strong>of</strong> a new multidisciplinary‘one-stop-shop’ outpatient facility).Rheumatologists must be proactive and show leadership in service developments for their specialty.They must engage and negotiate both <strong>with</strong>in their employing trust and outside <strong>with</strong> commissionersto secure high-quality services for their <strong>patients</strong>.Agreeing standards <strong>of</strong> care <strong>with</strong> other providers and commissioners on a regional basis may preventvariation and fluctuation in service funding and provision. An example <strong>of</strong> this is the model <strong>of</strong>10 standards in inflammatory arthritis being developed by the rheumatologists <strong>with</strong>in the EastAnglian Strategic Health Authority.Guidance to help rheumatologists develop and strengthen their services is available from the BSR. 63Undergraduate and postgraduate training are essential parts <strong>of</strong> the work <strong>of</strong> most rheumatologists.The time commitment for this will vary but must be included in the agreed job plan.The rheumatologist has an important role in the training and CPD <strong>of</strong> allied pr<strong>of</strong>essionals and GPs sothat future multidisciplinary and integrated care <strong>of</strong> <strong>patients</strong> <strong>with</strong> musculoskeletal disorders is <strong>of</strong> thehighest standard.Rheumatologists would be expected to enrol in the RCP’s CPD programme. They should have timeallocation and funding for 10 days <strong>of</strong> study leave a year.The BSR holds various meetings, including a 4-day annual general meeting <strong>with</strong> educational andoriginal research sessions. The society has its own journal, Rheumatology.Currently appraisal <strong>of</strong> rheumatologists follows individual trust requirements. Enhanced appraisal willsoon be linked to revalidation.Rheumatologists will mentor, appraise and assess colleagues, trainees and other pr<strong>of</strong>essionals in theMDT.Clinical governance is based on best practice and national guidance.Local, regional and national audit must underpin the governance process. The BSR has a programme<strong>of</strong> national audits. The first <strong>of</strong> these looked at access to specialist services for <strong>patients</strong> <strong>with</strong>rheumatoid arthritis and compliance <strong>with</strong> guidelines in osteoarthritis.Rheumatology has a strong academic and research base. Many trainees in the specialty spend sometime in pure research, which <strong>of</strong>ten leads to the award <strong>of</strong> higher degrees.<strong>Consultant</strong> rheumatologists should be encouraged to continue and develop their research interests.The Comprehensive Local Research Networks under the auspices <strong>of</strong> the National Institute for HealthResearch (NIHR) can help facilitate this and there are many opportunities for multicentre clinicalresearch.The BSR biologics registry (BSRBR) monitors the long-term safety <strong>of</strong> biologic drugs given forrheumatoid arthritis. 64British rheumatology research is well regarded internationally. Recent examples where basic sciencehas supported clinical research leading to important advances in clinical care are the introduction <strong>of</strong>anti-TNF agents and an anti-CD20 monoclonal antibody for the treatment <strong>of</strong> severe rheumatoidarthritis.Rheumatologists are well represented at all levels <strong>of</strong> clinical management and pr<strong>of</strong>essional activity.Local work may include clinical leadership or other roles such as undergraduate dean or Caldicottguardian.Regional and national work might be for the royal colleges, DH, NICE, specialist societies or deaneries.The BSR has a regional structure across the UK. The society has a close <strong>working</strong> relationship <strong>with</strong> theRCP, <strong>with</strong> representation on the Joint Specialty Committee and the president sitting on the RCP’scouncil.The BSR has very active clinical affairs and external relations departments, which respond regularly toNICE appraisals and consultation papers from the DH.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 241


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 6 Patient allocation to non-consultant staffHealthcarepr<strong>of</strong>essionalNew<strong>patients</strong> or Review <strong>patients</strong>FY1/FY2 2 4 (consider assupernumerary,although theyshould see <strong>patients</strong>)GP clinicalassistant3–4 or 7–10StR 2–4 or 6–10 depending onexperienceStaff grade 5 or 10Associatespecialist6–7 or 12–15 (same asconsultant)Nurse practitioner 6–8 65future, <strong>with</strong> support for GPwSIs and extended-scopepractitioners.Day-case workThe number <strong>of</strong> <strong>patients</strong> managed in day-case unitsrather than being admitted is increasing. <strong>Consultant</strong>s<strong>of</strong>ten provide support for: assessment and supervision <strong>of</strong> biologic andcytotoxic drug therapy therapeutic procedures such as joint injections,which are increasingly undertaken <strong>with</strong> ultrasoundguidance.Inpatient workImproved management <strong>of</strong> <strong>patients</strong> has resulted in asignificant reduction in rheumatology inpatientadmissions, and only a minority <strong>of</strong> units have dedicatedinpatient beds. Patients who require admission areusually admitted by acute medical teams, but these<strong>patients</strong> <strong>of</strong>ten have complex disease <strong>with</strong>life-threatening complications and require prolongedlengths <strong>of</strong> stay. <strong>Consultant</strong> rheumatologists need towork closely <strong>with</strong> the medical teams to provideongoing care.Specialist on callA significant reduction in the number <strong>of</strong>rheumatologists being asked to provide on-call coverhas been seen, <strong>with</strong> a potential impact on quality <strong>of</strong> careand training <strong>of</strong> juniors. If on-call support is notprovided by the hospital trust, adequate provision forward rounds should be built into consultants’ job plans.7 Opportunities for integrated careMultisystem inflammatory diseases <strong>with</strong> associated risks<strong>of</strong> serious morbidity and mortality are at the core <strong>of</strong>rheumatology and require early, active, multispecialtymanagement and acute care, <strong>of</strong>ten in the hospitalsetting. However, integrated care <strong>with</strong> the community<strong>of</strong>fers real opportunities for many <strong>patients</strong> and could beconsidered under two categories: improvement in care<strong>of</strong> long-term inflammatory conditions and optimisation<strong>of</strong> non-inflammatory conditions via directed-carepathways. Proposed changes in service design may meanthat some services are run by GP consortia, whileothers may be run under close integration <strong>with</strong>secondary care.Inflammatory conditions, eg rheumatoid arthritis,require rapid access to the MDT, investigations anddiagnosis. Conditions generally require long-termmanagement, including specialist therapies andconsideration <strong>of</strong> comorbidity and risk. Initialrheumatology input is intensive, but most <strong>patients</strong> <strong>with</strong>stable disease could be managed via shared care <strong>with</strong>general practice and infrequent, usually annual,rheumatology review. 16 Improving shared care couldreduce follow-up rates, improve capacity forrapid-access services for new and flaring <strong>patients</strong>, andperhaps <strong>of</strong>fer opportunities to optimiseunder-resourced areas, eg podiatry and psychology.Good examples <strong>of</strong> community-based services exist forback pain, osteoarthritis and other s<strong>of</strong>t-tissueconditions. Initial management occurs in generalpractice, <strong>with</strong> escalation to a musculoskeletal clinicalassessment/triage service staffed by extended-scopepractitioners or GPwSIs and linked to rheumatology ororthopaedic services in secondary care. The challengefor these services is to ensure that they provide quality,safety and good governance and that they dovetail <strong>with</strong>secondary care to avoid duplication. Other specialisedservices may also benefit from a coordinated approach,such as DXA for osteoporosis as part <strong>of</strong> a fractureliaison and metabolic bone disease service to improvepatient care and reduce long-term healthcare and socialcare usage, eg by prevention <strong>of</strong> hip fractures.With the engagement <strong>of</strong> existing rheumatology services,high-quality, productive, integrated care could be242 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties RheumatologyTable 7 Regional variations in number <strong>of</strong>rheumatologists per population (updated 2013)RegiondescriptionNo. <strong>of</strong>consultantsPopulationPopulation/consultantEast Midlands 29 4,279,707 147,576East <strong>of</strong>England39 5,491,293 140,802North east 23 2,54,5073 110,655South central 38 3,992,301 105,061South-eastcoast33 4,187,941 126,907South west 53 5,038,200 950,60WestMidlandsYorkshire andHumber57 5,334,006 935,8047 5,038,849 107,210North west 48 6,827,170 142,233London 106 7,428,590 70,081Scotland 39 5,222,100 133,900NorthernIreland17 1,799,392 105,847Wales 28 3,006,400 107,371delivered safely and effectively in various settings(eg hospital, polyclinic and CATS) tailored to the localpopulation. Involvement <strong>of</strong> local rheumatologists mustbe considered early in service development to ensureefficient access to investigations, imaging andthe MDT.8 Workforce requirements for the specialtyData from a recent national survey <strong>of</strong> rheumatologistsin the UK indicates the following (Table 7): 66 Rheumatology continues to be an expandingdiscipline; between 2007 and 2009:– The number <strong>of</strong> consultants in England, Wales,Northern Ireland and Scotland increased from584 to 641 – an increase <strong>of</strong> 9.7%.– Whole-time equivalents (WTEs) increased by13% from 470 to 531. 73% <strong>of</strong> rheumatologists work purely inrheumatology. 14% <strong>of</strong> rheumatologists undertake acute medicine. Currently, one rheumatologist is in place per114,831 population in the UK, <strong>with</strong> wide regionalvariations. Recently, some retirement posts have not been filleddue to funding shortfalls; this expansion <strong>of</strong> thediscipline may plateau or even decreasedepending on the effects <strong>of</strong> current changes inthe NHS.<strong>Consultant</strong> programmed activities (PAs) for aservice for a population <strong>of</strong> 250,000Different patterns <strong>of</strong> <strong>working</strong> across the UK, together<strong>with</strong> different referral patterns from GPs, lead toconsiderable variation in patient numbers inrheumatology units. The consultant requirement,measured as the number <strong>of</strong> PAs needed to provide aservice, depends on the volume <strong>of</strong> inpatient andoutpatient work. Estimates have been made based onepidemiological, needs-based assessments <strong>of</strong> thenumber <strong>of</strong> incident and prevalent cases <strong>of</strong>musculoskeletal conditions likely to present to primarycare, and the estimated proportion <strong>of</strong> these cases thatwould benefit from assessment, treatment andfollow-up in secondary care; the data are supplementedby a large audit performed across 17 units in theMidlands. 3,16,67–69 One WTE consultant is required per 86,000population (2.9 WTE per 250,000). To achieve this would require a total <strong>of</strong> 648consultants, but there is currently a shortfall <strong>of</strong>117 rheumatology consultants. The data assume that a consultant provides4.5 clinics a week for 42 weeks per year, giving a total<strong>of</strong> 189 clinics per year. These data will obviously change depending onregional variations in patient demographics andmodels <strong>of</strong> care. Non-inflammatory conditions such as back pain,osteoarthritis, osteoporosis and regional conditionshave greater unit variations and depend on localpractice and specialist interests. Local commissioning must take into considerationincident cases <strong>of</strong> inflammatory arthritis andprovision for follow-up in accordance <strong>with</strong> NICEguidance.9 <strong>Consultant</strong> work programme/specimenjob planTables 8–10 show specimen job plans for differentscenarios.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 243


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 8 Full-time rheumatologistActivity Workload Programmed activities (PAs)Direct clinical care4–5 outpatient clinics and associatedadministration (administration approximately0.25 sessions per clinic)Ward work, inpatient referrals, day unit andMDT support5–61Patient-related administration 1Total number <strong>of</strong> direct clinical care PAs7.5 on averageSupporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong>healthcareOther NHS responsibilitiesExternal dutiesTeaching, training, appraisal, audit, clinicalgovernance, CPD, revalidation, research,departmental management and servicedevelopmenteg medical director/clinical director/leadconsultant in specialty/clinical tutoreg work for deaneries/royal colleges/specialistsocieties/DH or other government bodies, etc2.5 on averageLocal agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trustTable 9 Rheumatologist <strong>with</strong> GIMActivity Workload Programmed activities (PAs)Direct clinical careOn-call dutiesTotal number <strong>of</strong> direct clinical care PAsSupporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong>healthcareOther NHS responsibilitiesExternal duties3–4 outpatient clinics and associatedadministration (administration approximately0.25 sessions per clinic)GIM and specialty ward round, inpatientreferrals, day unit and MDT supportPatient-related administration, relatives andcontactPeri- and post-take ward rounds weekdays andweekends (1:10)Teaching, training, appraisal, audit, clinicalgovernance, CPD, revalidation, research,departmental management and servicedevelopmenteg medical director/clinical director/leadconsultant in specialty/clinical tutoreg work for deaneries/royal colleges/specialistsocieties/DH or other government bodies, etc4–52118.5 on average2.5 on averageLocal agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trust244 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties RheumatologyTable 10 Full-time academic clinical rheumatologistActivity Workload Programmed activities (PAs)Direct clinical careAcute trustSpecialist patient clinics plus associatedadministration (administration approximately0.25 sessions per clinic)1.5Ward round and inpatient referrals 1Research academic sessions – universityTotal number <strong>of</strong> direct clinical care andacademic PAsSupporting pr<strong>of</strong>essional activities (SPAs)Work to maintain and improve the quality <strong>of</strong>healthcareOther NHS responsibilitiesExternal dutiesFull academic sessions (this is an example; theexact work balance will vary considerably fromone individual to the next)Teaching and training, appraisal, audit, clinicalgovernance, CPD, revalidation, some aspects <strong>of</strong>academic work.eg medical director/clinical director/leadconsultant in specialty/clinical tutoreg work for deaneries/royal colleges/specialistsocieties/DH or other government bodies, etc57.5 (average)2.5 (average)Local agreement <strong>with</strong> trustLocal agreement <strong>with</strong> trust10 Key points for commissioners1 Commissioning for rheumatic diseases mustensure that <strong>patients</strong>’ needs are at the centre <strong>of</strong>service planning and support the concept <strong>of</strong> ‘nodecision about me <strong>with</strong>out me’.2 <strong>Consultant</strong>s, as well as all other key healthcarepr<strong>of</strong>essionals, such as specialist nurses,physiotherapists and occupationaltherapists, should be involved incommissioning <strong>of</strong> rheumatology services ata local level.3 Many rheumatic diseases are complex,chronic, disabling and life shortening.Successful commissioning must includelong-term planning, <strong>with</strong> integrated pathwaysbetween primary and secondary care, includingsocial support.4 Commissioning must involve patientrepresentation through organisations such as localARMA networks, National Rheumatoid ArthritisSociety (NRAS) and Arthritis Care.5 The introduction <strong>of</strong> competition in commissioning<strong>of</strong> services brings a risk <strong>of</strong> fragmentation <strong>of</strong> existinggood-quality clinical networks, which are essentialfor management <strong>of</strong> rheumatic diseases.6 Commissioning must focus on quality andoutcome measures (including the ability to work)rather than on targets that may not be clinicallyrelevant.7 Quality <strong>of</strong> services should be assessed by qualitymetrics and by (multicentre or national) auditsagainst national standards produced by bodies suchas NICE, the BSR and the RCP.8 Commissioning must conform to NICE clinicalguidance and technology appraisals but should alsobe flexible enough to recognise that some <strong>patients</strong><strong>with</strong> severe progressive rheumatic diseases shouldnot be disadvantaged because their condition hasnot been assessed by NICE.9 Commissioning must recognise the clinicalimportance and potential cost benefit <strong>of</strong> earlyreferral and specialist treatment for rheumaticdiseases, as highlighted by NICE guidance, the18-week commissioning pathway for inflammatoryarthritis and the National Audit Office’s report onservices for rheumatoid arthritis. 510 Crude ratios <strong>of</strong> new <strong>patients</strong> to follow-up <strong>patients</strong>do not reflect service quality in rheumatology unitsand must be analysed in the context <strong>of</strong> the localclinical casemix, staffing and model <strong>of</strong> serviceprovision.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 245


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Services for people <strong>with</strong> rheumatoidarthritis. London: NAO, 2009. www.nao.org.uk/publications/0809/services for people <strong>with</strong> rheum.aspx[Accessed 1 July 2011].6 Samanta A, Roy S, Feehally J, Symmons DP. Theprevalence <strong>of</strong> diagnosed systemic lupus erythematosus inWhites and Indian Asian migrants in Leicester city, UK.Br J Rheum 1992;31:679–82.7 Silman A, Jannini S, Symmons D, Bacon P. Anepidemiological study <strong>of</strong> scleroderma in the WestMidlands. Br J Rheum 1988;27:286–90.8 Cr<strong>of</strong>t P, Rigby AS, Boswell R, et al. The prevalence <strong>of</strong>chronic widespread pain in the general population. JRheumatol 1993;20:710–3.9 Symmons DP, Jones M, Osborne J, et al.Paediatricrheumatology in the United Kingdom: data from theBritish Paediatric Rheumatology National GroupDiagnostic Register. J Rheumatol 1996;23:1975–88.10 Department <strong>of</strong> Health. The musculoskeletal servicesframework. London: DH, 2006.11 Department <strong>of</strong> Health. Equity and excellence: liberatingthe NHS. London: DH, 2010. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 117353 [Accessed 1July 2011].12 British Society for Paediatric and AdolescentRheumatology. BSPAR position statement on pr<strong>of</strong>essionals<strong>working</strong> in paediatric rheumatology. Birmingham:BSPAR: 2007. www.bspar.org.uk/downloads/clinicalguidelines/Final BSPAR Position Statement onPr<strong>of</strong>essionals <strong>working</strong> in Paediatric RheumatologyTeams.pdf13 British Society for Rheumatology. Musculoskeletaldisorders: providing for the patient’s needs. No. 1. Therole <strong>of</strong> rheumatology departments. London: BSR,1992.14 British Society for Rheumatology. Guidelines on themanagement <strong>of</strong> rheumatoid arthritis. London: BSR,2006.15 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong>care – care documents. London: ARMA, 2006. www.arma.uk.net/care.html [Accessed 1 July 2011].16 National Institute for Health and Care Excellence. Themanagement <strong>of</strong> rheumatoid arthritis in adults.London:NICE, 2010. www.nice.org.uk/CG79 [Accessed 1 July2011].17 Carr A. Defining the extended clinical role for alliedhealth pr<strong>of</strong>essionals in rheumatology. In: ARC conferenceproceedings. No 12. Chesterfield: Arthritis ResearchCampaign, 2001.18 Hay EM, Campbell A, Linney S, et al. Development <strong>of</strong> acompetency framework for general practitioners <strong>with</strong> aspecial interest in musculoskeletal/rheumatologypractice. Rheumatology 2007;46:360–2.19 Arthritis and Musculoskeletal Alliance. Joint <strong>working</strong>? Anaudit <strong>of</strong> the Department <strong>of</strong> Health’s musculoskeletalservices framework. Exeter: ARMA, 2009. www.arma.uk.net/pdfs/MSF%20Review FINAL1.pdf [Accessed 4July 2011].20 Arthritis and Musculoskeletal Alliance. Themusculoskeletal map <strong>of</strong> England. Exeter: ARMA, 2010.www.arma.uk.net/pdfs/Musculoskeletal%20map%20FINAL%202.pdf [Accessed 4 July 2011].21 Department <strong>of</strong> Health. 18 week commissioning pathwayinflammatory arthritis (joint pain). London: DH, 2009.www.nras.org.uk/includes/documents/cm docs/2010/i/ia pathway.pdf [Accessed 4 July 2011].22 British Society for Rheumatology. British Society forRheumatology and British Health Pr<strong>of</strong>essionals inRheumatology peer review scheme. London: BSR, 2010.www.rheumatology.org.uk/includes/documents/cmdocs/2010/p/2 peer review guidance 6 sept 2010.pdf[Accessed 4 July 2011].23 British Society for Rheumatology. British Society forRheumatology and British Health Pr<strong>of</strong>essionals inRheumatology peer review scheme: peer review visitpr<strong>of</strong>orma. London: BSR, 2010. www.rheumatology.org.uk/includes/documents/cm docs/2010/p/peerreview pr<strong>of</strong>orma aug 2010.doc [Accessed 4 July 2011].24 National Institute for Health and Care Excellence.Musculoskeletal. London: NICE, 2011. http://guidance.nice.org.uk/Topic/Musculoskeletal [Accessed 4 July2011].25 National Institute for Health and Care Excellence. Thecare and management <strong>of</strong> osteoarthritis in adults. London:NICE, 2008. http://guidance.nice.org.uk/CG59 [Accessed4 July 2011].26 National Institute for Health and Care Excellence.Etanercept for the treatment <strong>of</strong> juvenile idiopathic arthritis.London: NICE, 2002. http://guidance.nice.org.uk/TA35[Accessed 4 July 2011].246 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Rheumatology27 National Institute for Health and Care Excellence.COX-II inhibitors for the treatment <strong>of</strong> osteoarthritis andrheumatoid arthritis. London: NICE, 2001.http://guidance.nice.org.uk/TA27 [Accessed 4 July2011].28 National Institute for Health and Care Excellence.Etanercept, infliximab and adalimumab for thetreatment <strong>of</strong> psoriatic arthritis. London: NICE, 2010.http://guidance.nice.org.uk/TA199 [Accessed 4 July2011].29 National Institute for Health and Care Excellence. Theclinical effectiveness and cost effectiveness <strong>of</strong> etanercept andinfliximab for rheumatoid arthritis and juvenilepoly-articular idiopathic arthritis. London: NICE, 2002.http://guidance.nice.org.uk/TA36 [Accessed 4 July2011].30 National Institute for Health and Care Excellence.Certolizumab pegol for the treatment <strong>of</strong> rheumatoidarthritis. London: NICE, 2010. http://guidance.nice.org.uk/TA186 [Accessed 4 July 2011].31 National Institute for Health and Care Excellence.Adalimumab, etanercept, infliximab, rituximab andabatacept for the treatment <strong>of</strong> rheumatoid arthritis afterthe failure <strong>of</strong> a TNF inhibitor. London: NICE, 2010.http://guidance.nice.org.uk/TA195 [Accessed 4 July2011].32 National Institute for Health and Care Excellence.Tocilizumab for rheumatoid arthritis. London: NICE,2010. http://guidance.nice.org.uk/TA198 [Accessed 4 July2011].33 National Institute for Health and Care Excellence.Febuxostat for the management <strong>of</strong> hyperuricaemia inpeople <strong>with</strong> gout. London: NICE, 2008. http://guidance.nice.org.uk/TA164 [Accessed 4 July 2011].34 National Institute for Health and Care Excellence.Alendronate, etidronate, risedronate, raloxifene andstrontium ranelate for the primary prevention <strong>of</strong>osteoporotic fragility fractures in postmenopausal women.London: NICE, 2011. http://guidance.nice.org.uk/TA160[Accessed 4 July 2011].35 National Institute for Health and Care Excellence. Theclinical effectiveness and cost effectiveness <strong>of</strong> technologiesfor the secondary prevention <strong>of</strong> osteoporotic fractures inpostmenopausal women. London: NICE, 2005.http://guidance.nice.org.uk/TA87 [Accessed 4 July2011].36 British Society for Rheumatology. Guidelines.London:BSR, 2011. www.rheumatology.org.uk/resources/guidelines/default.aspx [Accessed 4 July 2011].37 Ding T, Ledingham J, Luqmani R, et al. BSR and BHPRrheumatoid arthritis guidelines on safety <strong>of</strong> anti-TNFtherapies. Rheumatology 2010;49:2217–9. www.rheumatology.org.uk/includes/documents/cm docs/2010/r/ra guidelines on safety <strong>of</strong> antitnf therapiessept 2010.pdf [Accessed 4 July 2011].38 Dasgupta B, Borg FA, Hassan N, et al. BSR and BHPRGuidelines for the management <strong>of</strong> giant cell arteritis.Rheumatology 2010;49:1594–7. www.rheumatology.org.uk/includes/documents/cm docs/2010/m/2management <strong>of</strong> giant cell arteritis.pdf [Accessed 4July 2011].39 Deighton C, Hyrich K, Ding T, et al. BSR and BHPRrheumatoid arthritis guidelines on eligibility criteria forthe first biological. Rheumatology 2010;49:1594–7.www.rheumatology.org.uk/includes/documents/cmdocs/2010/r/2 ra guidelines on eligibility criteria forthe first biological therapy.pdf [Accessed 4 July2011].40 British Society for Rheumatology and British HealthPr<strong>of</strong>essionals in Rheumatology. Quick reference guidelinefor monitoring <strong>of</strong> disease modifying anti-rheumatic drug(DMARD) therapy. London: BSR, BHPR, 2009.www.rheumatology.org.uk/includes/documents/cmdocs/2009/d/dmard grid november 2009.pdf [Accessed4 July 2011].41 Dasgupta B, Borg FA, Hassan N, et al. BSR and BHPRguidelines for the management <strong>of</strong> polymyalgiarheumatica. Rheumatology 2010;49:186–90. www.rheumatology.org.uk/includes/documents/cm docs/2009/m/management <strong>of</strong> polymyalgia rheumatica.pdf[Accessed 4 July 2011].42 Luqmani R, Hennel S, Estrach C, et al. British Society forRheumatology and British Health Pr<strong>of</strong>essionals inRheumatology guideline for the management <strong>of</strong>rheumatoid arthritis (after the first 2 years).Rheumatology 2009;48:436–9. www.rheumatology.org.uk/includes/documents/cm docs/2009/m/management<strong>of</strong> rheumatoid arthritis after first 2 years.pdf [Accessed4 July 2011].43 Chakravarty K, McDonald H, Pullar T, et al. BSR/BHPRguideline for disease-modifying anti-rheumatic drug(DMARD) therapy in consultation <strong>with</strong> the BritishAssociation <strong>of</strong> Dermatologists. Rheumatology2008;47:924–5. www.rheumatology.org.uk/includes/documents/cm docs/2009/d/diseasemodifyingantirheumatic drug dmard therapy.pdf [Accessed 4 July2011].44 Chakravarty K, McDonald H, Pullar T, et al. Appendix toBSR/BHPR guideline for disease-modifyinganti-rheumatic drug (DMARD) therapy. London: BSR,2010. www.rheumatology.org.uk/includes/documents/cm docs/2010/a/appendix to dmard guideline aug2010.pdf [Accessed 3 August 2011].45 LapraikC,WattsR,BaconP,et al. BSR and BHPRguidelines for the management <strong>of</strong> adults <strong>with</strong> ANCAassociated vasculitis. Rheumatology 2008;46:1615–6.www.rheumatology.org.uk/includes/documents/cm docs/2009/m/management <strong>of</strong> adults <strong>with</strong> ancaassociated vasculitis.pdf [Accessed 4 July2011].C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 247


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>46 Jordan KM, Cameron JS, Snaith M, et al. British Societyfor Rheumatology and British Health Pr<strong>of</strong>essionals inRheumatology guideline for the management <strong>of</strong> gout.Rheumatology 2007;46:1372–4. www.rheumatology.org.uk/includes/documents/cm docs/2009/m/management <strong>of</strong> gout.pdf [Accessed 4 July 2011].47 Luqmani R, Hennell S, Estrach C, et al. British Society forRheumatology and British Health Pr<strong>of</strong>essionals inRheumatology guideline for the management <strong>of</strong>rheumatoid arthritis (the first 2 years). Rheumatology2006;45:1167–9. www.rheumatology.org.uk/includes/documents/cm docs/2009/m/management <strong>of</strong>rheumatoid arthritis first 2 years.pdf [Accessed 4 July2011].48 Coakley G, Mathews C, Field M, et al. BSR & BHPR,BOA, RCGP and BSAC guidelines for management <strong>of</strong> thehot swollen joint in adults. Rheumatology2006;45:1039–41.www.rheumatology.org.uk/includes/documents/cmdocs/2009/m/management <strong>of</strong> hot swollen joints inadults.pdf [Accessed 4 July 2011].49 Kyle S, Chandler D, Griffiths CEM, et al. Guideline foranti-TNF-α therapy in psoriatic arthritis. Rheumatology2005;44:390–7. www.rheumatology.org.uk/includes/documents/cm docs/2009/a/antitnf alpha therapyin psoriatic arthritis.pdf [Accessed 4 July 2011].50 Ledingham J, Deighton C. Update on the British Societyfor Rheumatology guidelines for prescribing TNFαblockers in adults <strong>with</strong> rheumatoid arthritis (update <strong>of</strong>previous guidelines <strong>of</strong> April 2001). Rheumatology2005;44:157–63. www.rheumatology.org.uk/includes/documents/cm docs/2009/p/prescribing tnf blockersin adults <strong>with</strong> rheumatoid arthritis.pdf [Accessed 4 July2011].51 Kennedy T, McCabe C, Struthers G, et al. BSR guidelineson standards <strong>of</strong> care for persons <strong>with</strong> rheumatoidarthritis. Rheumatology 2005;44:553–6. www.rheumatology.org.uk/includes/documents/cm docs/2009/s/standards <strong>of</strong> care for persons <strong>with</strong>rheumatoid arthritis.pdf [Accessed 4 July 2011].52 Keat A, Barkham N, Bhalla A, et al. BSR guideline forprescribing TNFα blockers in adults <strong>with</strong> ankylosingspondylitis. London: BSR, 2004. www.rheumatology.org.uk/includes/documents/cm docs/2009/p/prescribing tnf alpha blockers in adults <strong>with</strong>ankylosing spondylitis.pdf [Accessed 4 July 2011].53 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong> care– project overview. Exeter: ARMA, 2011. www.arma.uk.net/overview.html [Accessed 4 July 2011].54 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong> carefor people <strong>with</strong> back pain. Exeter: ARMA, 2004.www.arma.uk.net/pdfs/bp06.pdf [Accessed 4 July 2011].55 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong> carefor people <strong>with</strong> inflammatory arthritis. Exeter: ARMA,2004. www.arma.uk.net/pdfs/ia06.pdf [Accessed 4 July2011].56 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong> carefor people <strong>with</strong> osteoarthritis. Exeter: ARMA, 2004.www.arma.uk.net/pdfs/oa06.pdf [Accessed 4 July2011].57 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong> carefor people <strong>with</strong> connective tissue diseases. Exeter: ARMA,2007. www.arma.uk.net/pdfs/ctdweb.pdf [Accessed 4 July2011].58 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong> carefor people <strong>with</strong> metabolic bone disease. Exeter: ARMA,2007. www.arma.uk.net/pdfs/mbdweb.pdf [Accessed 4July 2011].59 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong> carefor people <strong>with</strong> regional musculoskeletal pain. Exeter:ARMA, 2007. www.arma.uk.net/pdfs/rmpweb.pdf[Accessed 4 July 2011].60 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong> carefor people <strong>with</strong> musculoskeletal skeletal conditions:overarching principles. Exeter: ARMA, 2004. www.arma.uk.net/pdfs/Overarching%20Principles.pdf [Accessed 4July 2011].61 Arthritis and Musculoskeletal Alliance. Standards <strong>of</strong> carefor people <strong>with</strong> musculoskeletal foot health problems.Exeter: ARMA, 2004. www.arma.uk.net/pdfs/musculoskeletalfoothealthproblems.pdf [Accessed 4 July2011].62 Arthritis and Musculoskeletal Alliance. ARMA charter forwork for people affected by musculoskeletal disorders in theUK. Exeter: ARMA, 2010. www.arma.uk.net/pdfs/ARMA%20work%20charter%20FINAL.pdf [Accessed 4July 2011].63 British Society for Rheumatology. London: BSR.www.rheumatology.org.uk/members/action plan.aspx[Accessed 4 July 2011].64 British Society for Rheumatology. The BSR BiologicsRegister. London: BSR. www.rheumatology.org.uk/bsrbiologics register/default.aspx [Accessed 4 July 2011].65 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Nursing. Rheumatology nursing. Result<strong>of</strong> a survey exploring the performance and activity <strong>of</strong>rheumatology nurses. London: RCN. www.rcn.org.uk66 Bukhari M, Dixey J, Deighton C. A survey <strong>of</strong> new t<strong>of</strong>ollow-up ratios in rheumatology outpatientdepartments. Clin Med 2011;11:99–100.67 Baskar S, Obrenovic, Hirsch G, et al. West and EastMidlands region-wide rheumatology case mixsurvey. Rheumatology 2010;49(suppl 1):i24 (PosterOP55).68 Harrison MJ, Deighton C, Symmons DP. An update onUK rheumatology consultant workforce provision: theBSR/ARC Workforce Register 2005–07: assessing theimpact <strong>of</strong> recent changes in NHS provision.Rheumatology 2008;47:1065–9.248 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Rheumatology69 Musculoskeletal Research Group. Norfolk ArthritisRegister (NOAR) information. Manchester: University <strong>of</strong>Manchester, 2010. www.medicine.manchester.ac.uk/musculoskeletal/research/arc/clinicalepidemiology/outcomestudies/noar/noarinfo/ [Accessed 1 July 2011].Appendix (2013 update)Major changes in the commissioning <strong>of</strong> rheumatologyservices will occur in April 2013 in England, <strong>with</strong> theintroduction <strong>of</strong> clinical commissioning groups (CCGs).CCGs will commission locally the majority <strong>of</strong> workundertaken by rheumatology services. Some specialisedservices will be commissioned by the NationalCommissioning Board.Best practice tariff for earlyinflammatory arthritisIn April 2013 the Department <strong>of</strong> Health is introducing abest practice tariff (BPT) for early inflammatoryarthritis (EIA). This tariff is intended to support NHSproviders and their rheumatology services in thedelivery <strong>of</strong> high-quality, evidence-based, cost-effectivecare to people <strong>with</strong> EIA. The BPT should incentiviserapid assessment and diagnosis and facilitate intensivetreatment <strong>of</strong> rheumatoid arthritis and other EIA in line<strong>with</strong> National Institute for Health and Care Excellence(NICE) clinical guideline CG79. The tariff is designed tocover all aspects <strong>of</strong> rheumatological care in the first yearafter referral (except for the costs <strong>of</strong> biologic drugs), andwill allow services to see <strong>patients</strong> according to theirclinical need, removing some <strong>of</strong> the difficulties aroundcommissioning <strong>of</strong> follow-up appointments andnew:follow-up ratios.Patients referred in to rheumatology services <strong>with</strong>suspected EIA will attract one <strong>of</strong> three tariff payments:BPT2. DMARD therapy BPTA best practice tariff payment for those <strong>patients</strong> <strong>with</strong>suspected EIA who: are seen <strong>with</strong>in 3 weeks <strong>of</strong> referral have DMARD (disease-modifying anti-rheumaticdrug) treatment initiated <strong>with</strong>in 6 weeks <strong>of</strong> referral receive regular follow-up and monitoring over firstyear <strong>of</strong> treatment <strong>with</strong> evidence <strong>of</strong> appropriatetitration <strong>of</strong> therapy.BPT3. Biologic therapy BPTA best practice tariff payment for <strong>patients</strong> <strong>with</strong>suspected EIA who: are seen <strong>with</strong>in 3 weeks <strong>of</strong> referral are diagnosed, <strong>with</strong> DMARD treatment initiated<strong>with</strong>in 6 weeks <strong>of</strong> referral receive regular follow-up and monitoring as perBPT2 over first year <strong>of</strong> treatment; biologic therapyprescribed and initiated in year 1.The precise costing for the BPT has yet to be finalised,but the tariff levels are intended to allow rheumatologyservices to provide intensity <strong>of</strong> care consistent <strong>with</strong>NICE CG79, using a mixture <strong>of</strong> nurse- andconsultant-delivered care.If services are unable (or choose not) to implement theEIA BPT, they will continue to be paid the standardrheumatology new and follow-up tariff. However, it ishoped that the financial incentives built into the BPTwill encourage providers to develop rheumatologyservices to have sufficient clinical capacity to providetimely assessment and intensive treatment.The BPT will apply only to <strong>patients</strong> <strong>with</strong> new EIAreferrals in their first year <strong>of</strong> care. All otherrheumatology referrals, and <strong>patients</strong> already underfollow-up will continue to attract the standard new andfollow-up payment-by-results tariffs.BPT1. Diagnosis and dischargeA best practice tariff payment for those <strong>patients</strong> <strong>with</strong>suspected EIA who are: seen <strong>with</strong>in 3 weeks <strong>of</strong> referral diagnosed as not having EIA and discharged <strong>with</strong>in6 weeks <strong>of</strong> referral.The Scottish Public Health NetworkIn Scotland secondary care services are not‘commissioned’ through primary care, but are providedby health boards. However, the principles <strong>of</strong> shared care<strong>with</strong> primary care, early diagnosis and therapy <strong>of</strong>inflammatory arthritis, and multidisciplinary care areconsidered equally important. The Scottish PublicC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 249


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Health Network (ScotPHN) commissioned a needsassessment for rheumatoid arthritis which waspublished in 2012. The epidemiological section islargely based on data from the Norfolk ArthritisRegister (NOAR) and should thus be equally applicablein England, Wales and Ireland. The document includesan executive summary, epidemiological data,recommendations on the provision <strong>of</strong> core services forpeople <strong>with</strong> rheumatoid arthritis and cost implications(in draft form at the time <strong>of</strong> writing). These data may be<strong>of</strong> use to those commissioning services for rheumatoidarthritis in England, Wales and Northern Ireland as wellas rheumatologists and health boards in Scotland. Thewebsite for the ScotPHN is: www.scotphn.net/projects/previous projects/rheumatoid arthritis250 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Sport and exercise medicineSport and exercise medicineWilby Williamson MRCP MSc(SEM) Dip(SEM)Academic clinical fellow, sport and exercise medicineGraeme Wilkes MRCP MRCGP MSc(SEM) FFSEM<strong>Consultant</strong>, sport and exercise medicine1 Description <strong>of</strong> the specialtySport and exercise medicine (SEM) as a speciality hastwo objectives:1 Address the needs <strong>of</strong> physically active groups andkeep them active2 Contribute to primary and secondary diseaseprevention by promoting and increasing physicalactivity participation.Addressing the needs <strong>of</strong> physically active groups coversa broad spectrum <strong>of</strong> practice that is not exclusive tosports people and recreational athletes. SEM practicecrosses the lifespan, treating children and adolescents<strong>with</strong> musculoskeletal complaints that preventparticipation in school activities and hobbies through toolder adults <strong>with</strong> decline in mobility. Occupationallybased SEM practice helps adults to remain in activejobs, such as members <strong>of</strong> the armed services, publicsector, construction industries, agriculture and otherlabour-intensive jobs, by managing musculoskeletalcomplaints. Clinical practice relating to sport andstructured exercise addresses the clinical needs <strong>of</strong> the15–25% <strong>of</strong> the UK population that regularly participatein sport and structured activity. 1 This clinical practiceranges from <strong>of</strong>fering sports injury clinics to <strong>working</strong><strong>with</strong> local, national and international sports teams ininjury prevention and management.Sedentary behaviour and inactivity are majorcontributors to musculoskeletal disease, reducedwellbeing and cardiovascular morbidity/mortality. Theburden <strong>of</strong> physical inactivity extends across diseasegroups and impacts on society throughout our lifespan.Physical inactivity contributes to 5.3 million deathsworld-wide and is recognised by the World HealthOrganization as one <strong>of</strong> the five most significant riskfactors for chronic disease and reduced life expectancy. 2Physical activity is integral to healthy growth anddevelopment yet, in the UK, only 70% <strong>of</strong> 10 year oldsand less than 30% <strong>of</strong> 15 year olds achieve physicalactivity guidelines <strong>of</strong> 60 minutes <strong>of</strong> moderate tovigorous activity per day. 3 Inactivity and sedentarybehaviour continue to increase across the lifespan, <strong>with</strong>less than 8% <strong>of</strong> older adults engaging in the adultrecommended levels <strong>of</strong> 150 minutes <strong>of</strong> moderate tovigorous activity per week. 3 SEM consultants <strong>working</strong>in physical activity promotion undertake roles inenvironments ranging from primary prevention inpopulation and community interventions to secondaryprevention in lifestyle behaviour clinics and chronicdisease management.To meet the broad demands <strong>of</strong> clinical practice SEMconsultants undergo 6 years <strong>of</strong> specialist trainingpost-foundation training. SEM speciality trainingcovers chronic diseases, exercise physiology, publichealth medicine, acute and emergency medicine,general practice, musculoskeletal and team medicine,as well as solid grounding in education, teaching andresearch.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralInvestment in sport and exercise medicine andimproving equity in public access to SEM services are <strong>of</strong>pressing national importance. The expansion anddevelopment <strong>of</strong> SEM services to date have largelyevolved around the efforts <strong>of</strong> proactive, innovative andindustrious individuals at regional levels. To dateinvestment by NHS commissioners on behalf <strong>of</strong> their<strong>patients</strong> has been low. Sporadic regional development<strong>of</strong> service continues to support the bulk <strong>of</strong> NHSpractice.Regional efforts are now being supported by the NationalCentre for Sports and Exercise Medicine, based on threesites. The National Centre is a partnership betweenhospital trusts and universities from London, Sheffieldand the East Midlands. The Department <strong>of</strong> Health hasprovided capital funding to help develop three facilities,C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 251


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>one in each partner group, to speed up the translation<strong>of</strong> research into clinical practice. The funding <strong>of</strong>the National Centre is part <strong>of</strong> the government’s Olympiclegacy commitment, post-London 2012. It is anticipatedthat the National Centre will lead research and developmentto improve non-surgical musculoskeletal care andmusculoskeletal disease prevention. It will also work toestablish physical activity behavioural medicine services,particularly for those <strong>with</strong> chronic long-term conditions,many <strong>of</strong> whom could benefit from the expert prescription<strong>of</strong> exercise as part <strong>of</strong> their treatment. The NationalCentre for Sports and Exercise Medicine is a collaborativeinitiative <strong>with</strong> regional members. The regionaldevelopment <strong>of</strong> SEM outside these centres continuesto grow.The clinical roles undertaken by SEM <strong>physicians</strong> leadsto work in a variety <strong>of</strong> environments and manyconsultants would describe having portfolio careers. Asa specialty in the process <strong>of</strong> being established, regionalframeworks <strong>of</strong> clinical practice and organisationalstructure continue to evolve. Clinical practice can bebroadly grouped as community models <strong>of</strong> practice andsecondary care models.Community models <strong>of</strong> careIn a community setting, SEM consultants are <strong>working</strong><strong>with</strong> commissioners to develop locally agreedprotocols/pathways in order to facilitate effectivephysical activity prescription <strong>with</strong>in primary care andprompt access to appropriate musculoskeletal care.In community musculoskeletal clinics, SEMconsultants: provide a specialist opinion for <strong>patients</strong> andhealthcare pr<strong>of</strong>essionals close to the patient’s home introduce a unique skill set, including the use <strong>of</strong>diagnostic ultrasound and guided injectiontherapies, which expedites the diagnosis andmanagement <strong>of</strong> musculoskeletal problems provide support for other primary healthcarepr<strong>of</strong>essionals, such as extended-scopephysiotherapists (ESPs) and general practitioners<strong>with</strong> a specialist interest (GPwSIs) introduce a formal system <strong>of</strong> continuingpr<strong>of</strong>essional development (CPD) and appraisal for<strong>physicians</strong> <strong>working</strong> <strong>with</strong>in musculoskeletal services contribute to more efficient use <strong>of</strong> NHS funds for<strong>patients</strong> <strong>with</strong> musculoskeletal pathology throughcarefully considered and managed non-surgicalplans in partnership <strong>with</strong> physiotherapists.In chronic disease management promoting physicalactivity to achieve primary and secondary riskreduction, consultants <strong>working</strong> in community practiceundertake roles defined by local resources and physicalactivity initiatives. Practice might include individualpatient consultations <strong>with</strong> clinical risk assessments,physical activity measurement and behaviouralmodelling <strong>with</strong> outcome assessment at follow-up.Alternatively it might include physical activity servicesdevelopment, creating triage systems that are sensitiveto individual patient needs, coordinating localresources and establishing sustainable behaviouralinterventions.Models <strong>of</strong> secondary careIn secondary care, SEM consultants work <strong>with</strong>inmultidisciplinary teams and complement and expandcare options across: adult musculoskeletal services,musculoskeletal adolescent care, pain managementand chronic disease programmes. SEMconsultants: lead musculoskeletal and sports injuries clinics,alongside existing orthopaedic, physiotherapy andemergency department services, providingdiagnosis, treatment and rehabilitation <strong>of</strong>non-surgical musculoskeletal (including back pain),s<strong>of</strong>t-tissue and sports injuries establish chronic disease rehabilitation schemes thatare patient centred rather than disease centred andavailable to all, irrespective <strong>of</strong> morbidity provide a specialist service including clinical exercisetesting and risk assessment for <strong>patients</strong> <strong>with</strong> moreextensive or severe chronic disease andcomorbidities provide a specialist service including clinical exercisetesting to aid preoperative anaesthetic riskassessment provide an ongoing educational programme onevidence-based and effective exercise prescriptionfor teams <strong>working</strong> in specific chronic diseaseareas.3 Working <strong>with</strong> <strong>patients</strong>: patient-centredcareSEM services are centred on the patient and providenew options for healthcare providers in specialistexercise and musculoskeletal referrals. Patient choice isan important feature <strong>of</strong> these services, providingalternative options for <strong>patients</strong>. Many services areavailable in the community, close to home.252 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Sport and exercise medicineThe levels <strong>of</strong> physical activity and chronic disease <strong>of</strong>people from different ethnic, cultural and religiousgroups vary significantly. Equality, diversity and equity<strong>of</strong> access are integral considerations to SEM services,regardless <strong>of</strong> ethnic, religious or socioeconomic factors.Patients <strong>with</strong> chronic conditions are a priority for SEMservices, and consultants are involved in the prevention<strong>of</strong> chronic disease through health promotion, as well asin establishing chronic disease rehabilitation services.They are trained in evidence-based behaviour changetechniques, such as motivational interviewing,self-determination theory and social–cognitive theory.All these techniques improve efficacy for changingphysical activity behaviour and improve compliance<strong>with</strong> exercise prescription.4 Interspecialty and interdisciplinary liaisonSEM consultants are effective <strong>working</strong> at the centre <strong>of</strong>the care <strong>of</strong> those <strong>with</strong> musculoskeletal pathology. Theymay treat or sign-post the patient to appropriate otherclinicians or services. They can also work side by side<strong>with</strong> many different healthcare pr<strong>of</strong>essionals in effectivemultidisciplinary teams. These teams <strong>of</strong>ten includeorthopaedic surgeons, physiotherapists, podiatrists,occupational therapists, nurses, dietitians andpsychologists. In this way, SEM consultants work closely<strong>with</strong> other clinicians to reduce unnecessary burden ontheir services. This also ensures that <strong>patients</strong> are seeingthe most appropriate clinician based on the SEMconsultant understanding the pathology and the healthsystem.5 Delivering a high-quality service – howSEM contributesSEM involvement in services will contribute to delivery<strong>of</strong> improved and innovative patient care, contribute toefficiency in pathways and reduce the financial burdenon the NHS, both short and long term. Outside theirdirect patient contact role, SEM consultants can providecomprehensive and ongoing education onevidence-based and effective exercise prescription forapplication in primary care, as well as for teams<strong>working</strong> in specific chronic disease areas. They canintroduce a formal system <strong>of</strong> CPD, mentoring andappraisal for medical and other pr<strong>of</strong>essional staff<strong>working</strong> <strong>with</strong>in musculoskeletal interface services.Clinical governance will be a key feature <strong>of</strong> all existingand new SEM services, <strong>with</strong> active involvement in audit,critical event analysis and appraisal. Most SEM serviceshave an active programme <strong>of</strong> research, and this will beencouraged in new services as they are set up. Theestablishment and endorsement <strong>of</strong> the National Centrefor Sports and Exercise Medicine provides a foundationfor continued development in quality and standards.The National Centre will be tasked <strong>with</strong> beingexemplars in clinical and research excellence in sportand exercise medicine. The National Centre will forgetranslation <strong>of</strong> biomedical and behavioural research intoclinical practice, facilitating breakthroughs andinnovation to drive improvements in patient care. Thisincludes the establishment <strong>of</strong> protocols for processevaluation <strong>of</strong> clinical pathways and development <strong>of</strong>lean, sustainable organisational structures.6 Clinical work <strong>of</strong> consultantsThe work <strong>of</strong> SEM consultants includes (but is notlimited to): musculoskeletal and s<strong>of</strong>t-tissue diagnosis, treatmentand rehabilitation musculoskeletal pain management musculoskeletal injury prevention diagnostic musculoskeletal ultrasound andimage-guided s<strong>of</strong>t-tissue and joint injections physical activity health promotion management <strong>of</strong> exercise and physical activityinterventions assessment <strong>of</strong> chronic disease <strong>patients</strong> for theexercise referral service exercise prescription clinical exercise testing and risk stratification beforeexercise clinical exercise testing and risk stratification beforeanaesthesia advising on, and leading, workplace wellnessschemes.7 Workforce requirements for the specialtyCurrent workforce numbersSince 2006 79 trainees have entered SEM training.Currently there are 49 trainees across the UK onspecialist training schemes and 61 SEM <strong>physicians</strong> onthe specialist register helping to further thedevelopment <strong>of</strong> the speciality.Number <strong>of</strong> consultants requiredEmployment in the SEM field is still evolving so thesefigures are estimates only. Currently, there are 12 NHSC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 253


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>SEM services already in existence in secondary care,<strong>with</strong> many more community settings. The requirementfor SEM consultants will evolve according to specificlocal needs, but it is expected that a minimum <strong>of</strong> 2consultants will be required for a population <strong>of</strong> 330,000.This equates to 300 consultants across the UK. As theservices develop <strong>with</strong>in SEM, the number <strong>of</strong> consultantsrequired is likely to grow further, given the enormousnumber <strong>of</strong> <strong>patients</strong> <strong>with</strong> a chronic disease or at high risk<strong>of</strong> developing one, all <strong>of</strong> whom would benefit fromexercise prescription to help ease the burden <strong>of</strong> ill healthin an ageing population.8 Key points for commissioners1 Globally physical inactivity causes 9% <strong>of</strong> prematuredeaths, 5.3 million <strong>of</strong> the 57 million deaths thatoccurred in 2008. 22 Maintaining physical activity at recommend levelscan equate to 3–4 years in additional life expectancy<strong>with</strong> risk reductions <strong>of</strong> the order <strong>of</strong> 20–40% for over22 non-communicable diseases. 43 The NHS could make substantial savings bytargeting promotion <strong>of</strong> physical activity as part <strong>of</strong>chronic disease models. 54 Current costs <strong>of</strong> providing healthcare cover for aphysically inactive ageing population are notsustainable. 6,75 The NHS needs to invest proportionately to theburden <strong>of</strong> physical inactivity to develop sustainableprevention and treatment models for chronicdisease. 5–76 SEM consultants are trained in providingevidence-based and effective physical activityinterventions for primary and secondary prevention<strong>of</strong> chronic disease. 8–107 SEM consultants <strong>of</strong>fer unique and specificskills in the diagnosis, treatment and rehabilitation<strong>of</strong> musculoskeletal, s<strong>of</strong>t-tissue and sportinjuries.8 SEM services may be situated in both communityand secondary care settings, and tailored to meetlocal pressures and needs.References1 SportEngland’sActivePeople’sSurvey6.SportEngland,2012. www.sportengland.org/research/active peoplesurvey/active people survey 6.aspx [Accessed January2013].2 LeeI-M, ShiromaEJ, LobeloF, et al.Effect<strong>of</strong>physicalinactivity on major non-communicable diseasesworldwide: an analysis <strong>of</strong> burden <strong>of</strong> disease and lifeexpectancy. Lancet 2012; 380: 219–29.3 Townsend N, Bhatnagar P, Wickramasinghe K, et al.Physical activity statistics 2012. London: British HeartFoundation, 2012.4 Wen CP, Pui Man Wai J, Tsai MK, et al. Minimumamount <strong>of</strong> physical activity for reduced mortality andextended life expectancy: a prospective cohort study.Lancet 2011;378:1244–53.5 Jarret J, Woodcock J, Griffiths UK, et al. Effect <strong>of</strong>increasing active travel in urban England and Wales oncosts to the National Health Service. Lancet2012;379:2198–205.6 AndersonLH,MartinsonBC,CrainAL, et al. Healthcarecharges associated <strong>with</strong> physical inactivity, overweightand obesity. Prev Chronic Dis 2005;2(4):A09.7 Nazmi S. Physical inactivity and its impact on healthcareutilisation. Health Economics 2009;18:885–901.8 Moore G. The role <strong>of</strong> exercise prescription in chronicdisease. Br J Sports Med 2004;38:6–7.9 WeilerR, JonesN. Sports and exercise medicine: A freshapproach. NHS North West. www.northwest.nhs.uk/document uploads/2012/Sport-andExercise-Medicine-A-Fresh-Approach.pdf [Accessed January 2012].10 Pedersen BK, Saltin B. Evidence for prescribing exerciseas a therapy in chronic disease. ScandJMedSciSports2006;16(suppl 1):3–63.254 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Stroke medicineStroke medicineDr Helen Newton BM FRCP <strong>Consultant</strong> physician1 Description <strong>of</strong> the specialtyStroke is the most common cause <strong>of</strong> severe disabilityand the third most common cause <strong>of</strong> death in the UK. Itcosts the economy £8 billion a year (£3 billion in NHScosts; over 5% <strong>of</strong> NHS resources). 1 <strong>Consultant</strong>sspecialising in stroke are based in several specialties,commonly geriatric medicine or neurology. They arerepresented by the British Association <strong>of</strong> StrokePhysicians (BASP) who define the competencies androles <strong>of</strong> stroke specialists 2 and the stroke trainingcurriculum (www.basp.ac.uk).In an unprecedented development <strong>of</strong> stroke services, allhospitals in the UK now have a stroke unit and aneurovascular (transient ischaemic attack, TIA) clinic.Seventy-four per cent <strong>of</strong>fer 24-hour thrombolysis.However, improvements in acute care are not yetmatched by progress in delivering more effectivepost-hospital support. 3Who are the <strong>patients</strong>?A hospital serving a population <strong>of</strong> 300,000 admits about500 acute stroke <strong>patients</strong> each year. 4 Stroke servicesneed to plan for a further 20–25% <strong>of</strong> <strong>patients</strong> whopresent<strong>with</strong>strokemimics.ThecohortreferredtoTIAclinics contains a higher proportion <strong>of</strong> <strong>patients</strong> <strong>with</strong>alternative diagnoses, reflecting diagnostic uncertainty.The hospital described above might receive up to 500such referrals per year. Twenty-five per cent <strong>of</strong> <strong>patients</strong>are under 65. People from certain ethnic minorities areat a higher risk. Stroke <strong>patients</strong> need specialistrehabilitation either in hospital or at home, and toaccess further rehabilitation and support, <strong>of</strong>ten formany years.Main disease patternsStroke and TIA are part <strong>of</strong> the same spectrum <strong>of</strong>disease. By convention, TIA is diagnosed wheresymptoms resolve <strong>with</strong>in 24 hours, but this is not auseful distinction. Stroke and TIA should be managedin an integrated service. Patients <strong>with</strong> subarachnoidhaemorrhage have similar needs (eg rehabilitation) buta different pathway for acute care which is notaddressed here.2 Organisation <strong>of</strong> the service and patterns<strong>of</strong> referralA typical serviceA typical service comprises the following: Neurovascular (TIA) clinic: <strong>patients</strong> <strong>with</strong> suspectedTIAwhoareathighrisk<strong>of</strong>strokeshouldbeseenandinvestigated <strong>with</strong>in 24 hours, and all others <strong>with</strong>in 7days. 5 A 7-day service <strong>with</strong> immediate accessto appropriate brain and vascular imaging isneeded. Hyperacute stroke service: people <strong>with</strong> suspectedstroke must be conveyed immediately to a hospitalproviding thrombolysis 24 hours a day 5 andadmitted directly to a hyperacute stroke unit(HASU). 6 Twenty-four hour availability <strong>of</strong> anexperienced stroke physician and immediate accessto brain imaging is needed. Hospitals that cannotprovide a full hyperacute service participatein telemedicine schemes which are becomingwell established and researched. Some hospitalscontinue to need to operate a bypass arrangementto convey stroke <strong>patients</strong> to the nearest suitablehyperacute service ensuring that there are robustarrangements for this <strong>with</strong> emergency serviceproviders. 6 Acutestrokeunit(ASU):all hospitals admittingpeople <strong>with</strong> stroke must ensure that <strong>patients</strong> areadmitted directly to an ASU (or HASU). SUs shouldmeet specific geographical, organisational andstaffing crtieria. 6 Rehabilitation stroke unit (RSU): different modelsare effective including integration <strong>with</strong> the acuteunit and separate units in acute, intermediate orcommunity settings. Better outcomes are achievedwhen stroke pr<strong>of</strong>essionals oversee care. 7 Early supported discharge should be provided forsuitable <strong>patients</strong> and should consist <strong>of</strong> the sameintensity and skillmix as in hospital, <strong>with</strong>out delay indelivery. 6 Long-term management <strong>of</strong> disablity: awiderange<strong>of</strong>rehabilitation and support services must beprovided for <strong>patients</strong> and carers.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 255


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Box 1 Characteristics <strong>of</strong> effective stroke unitsKey characteristics <strong>of</strong> all stroke units 3<strong>Consultant</strong> physician <strong>with</strong> responsibility for strokeFormal links <strong>with</strong> patient and carer organisationsMultidisciplinary meetings at least once a week to plan patient careProvision <strong>of</strong> information to <strong>patients</strong> about strokeFunding for external courses and (monitoring <strong>of</strong>) uptakeAdditional key characteristics <strong>of</strong> acute stroke units 3Continuous physiological monitoring (ECG, oximetry, blood pressure)Immediate access to scanningDirect admission from A&E/front door (


2 Specialties Stroke medicineThe role <strong>of</strong> the carerA stroke in one person <strong>of</strong>ten affects the whole family,and relatives need information and support. 6 Familiesprovide much <strong>of</strong> the long-term care, <strong>of</strong>ten finding theirown lives radically altered. The needs <strong>of</strong> carers must beconsidered at each stage. Family support workers helpto reduce carer distress. 6Patient support groupsThe Stroke Association (www.stroke.org) plays a majorrole in developing, delivering and monitoring strokeservices. Different Strokes (www.differentstrokes.co.uk), Connect (www.ukconnect.org)andSpeakability (www.speakability.org.uk)alsoprovidewritten, web-based and telephone advice. Most areashave local support groups.Access to informationPatients <strong>with</strong> stroke and TIA report that one <strong>of</strong> theirmain needs is for information. This must be provided atappropriate times and in suitable formats includingthose suitable for people who do not speak English, andthose <strong>with</strong> stroke-related impairments such as visualand language difficulties.Availability <strong>of</strong> clinical records/resultsAvailability <strong>of</strong> clinical records, including results <strong>of</strong> brainimaging, is particularly important when the patientmoves from one part <strong>of</strong> the service to another.Role <strong>of</strong> the expert patientStroke <strong>patients</strong> should be routinely involved in serviceplanning and evaluation, 6 and may participate ineducation for staff and service users.4 Interspecialty and interdisciplinaryliaisonMultidisciplinary team <strong>working</strong>The specialist stroke team includes specialist strokenurses, therapists from all pr<strong>of</strong>essions and psychologists.Other pr<strong>of</strong>essions include orthotics and seating services,orthoptics and ophthalmology, podiatry, and hospitaland community social work services. The World HealthOrganization international classification <strong>of</strong> functioning,disability and health (WHO ICF) 8 provides a usefulframework for shared <strong>working</strong>. Documentation andtransfer <strong>of</strong> information are particularly important; astroke pr<strong>of</strong>orma and integrated record (shared by allmembers <strong>of</strong> the MDT) are good practice.Working <strong>with</strong> other specialistsPriority access to appropriate and specialised imaging is<strong>of</strong> fundamental importance. Stroke <strong>physicians</strong> alsowork closely <strong>with</strong> <strong>physicians</strong>, geriatricians, neurologists,vascular surgeons, neurosurgeons and accident andemergency (A&E) departments. Liaison <strong>with</strong> psychiatry(cognitive impairment, anxiety and depression),gastroenterology and nutrition (complex feedingissues), and <strong>with</strong> palliative care and pain managementteams, is expected.Working <strong>with</strong> GPs and GPs <strong>with</strong> aspecial interestStroke <strong>physicians</strong> work <strong>with</strong> the primary care team at allstages <strong>of</strong> the stroke pathway, including primary andsecondary prevention, acute care <strong>of</strong> people <strong>with</strong>stroke/TIA and long-term support <strong>of</strong> stroke <strong>patients</strong><strong>with</strong> residual disability.5 Delivering a high-quality servicePeoplewhohaveastrokearemorelikelytosurviveandrecover more function if admitted promptly to ahospital-based stroke unit <strong>with</strong> care provided by aspecialist team <strong>with</strong>in an integrated service. 7Maintaining and improving the quality<strong>of</strong> careService developments to improve the quality<strong>of</strong> careStroke care has been a focus for the Department <strong>of</strong>Health (DH) for over 10 years and a UK leader in theNational Sentinel Audit Programme (100%participation since 2004). The National sentinel strokeaudit 9 was developed by the RCP Stroke Programme(Clinical Effectiveness and Evaluation Unit, RCP,through the Intercollegiate Stroke Working Party,ICSWP). The National stroke strategy 7 was implementedby the Stroke Improvement Programme (DH) until 2012.Services for stroke <strong>patients</strong> have been transformedunder the influence <strong>of</strong> these and other key drivers (seeBox 2). BASP and the RCP have developed a Joint PeerReview Programme. Stroke is now a key component <strong>of</strong>the General Medical Services (GMS) contract forprimary care; there are seven key indicators for stroke inthe 2012–13 quality and outcomes framework (QOF). 10Stroke is also represented in the NHS outcomesframework 11 and the Clinical Commissioning GroupsOutcomes Indicator Set 2013–14. 12C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 257


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Box 2 Specialty and national guidelines and audits, quality tools and national frameworksSpecialty and national guidelines National clinical guideline for stroke, 4th edn 2012 6 NICE clinical guideline: management <strong>of</strong> acute stroke and TIA 2008 5 NICE Quality standard for stroke 2010 14 Stroke in childhood: clinical guidelines for diagnosis, management and rehabilitation 15 Meeting the future challenge <strong>of</strong> stroke. Stroke medicine consultant workforce requirements 2011–2015 (BASP) 4Specialty and national audit Sentinel Stroke National Audit Programme (SSNAP) 3 (previously: National Sentinel Stroke Audit 9 )and Stroke Improvement National Audit Programme (SINAP) 13 UK audit <strong>of</strong> vascular surgery services and carotid endarterectomy 16Quality tools and service frameworks National service framework for older people 2001 17 National service framework for long-term conditions 2005 18 Reducing brain damage: faster access to better stroke care 2005 19 Improving stroke services: a guide for commissioners 2006 20 National stroke strategy 2007 7 Welsh Health Circulars 058 and 082 2007 21 Improving stroke services in Northern Ireland. 2008 22 Progress in improving stroke care 2010 1Leadership role and the introduction <strong>of</strong> servicedevelopmentsStroke <strong>physicians</strong> play a key role in developing andimplementing modern stroke services.Education, training, mentoringand appraisalStroke <strong>physicians</strong> train and mentor members <strong>of</strong> thestroke team, and participate in education for staff,<strong>patients</strong> and carers.Continuing pr<strong>of</strong>essional developmentBASP holds regular educational meetings including anannual meeting, at the UK Stroke Forum. Strokepractitioners join relevant pr<strong>of</strong>essional societies andattend research and educational meetings as well asgeneral continuing pr<strong>of</strong>essional development (CPD)activities.Clinical governanceAll stroke <strong>physicians</strong> participate in local and nationalaudit and reporting. The National sentinel audit <strong>of</strong>stroke 9 (England, Wales and Northern Ireland) has beensuperseded by the Sentinel Stroke National AuditProgramme, SSNAP (currently for England). 3 Itcomprises organisational audits and prospective datacollection for all stroke <strong>patients</strong>. It will provide a coredataset, optional further data collection, spotlightaudits (on topics not regularly covered) and sprintaudits (focusing on areas <strong>of</strong> concern). Real-time datacollection for stroke <strong>patients</strong> in England commenced in2010 as the Stroke Improvement National AuditProgramme (SINAP). SINAP data for 10,069 <strong>patients</strong>admitted between July and September 2012 show thatthey had improved access to imaging (92% had a brainscan <strong>with</strong>in 24 hours), quicker time to arrival on astroke unit (66% <strong>with</strong>in 4 hours), and that more<strong>patients</strong> received thrombolysis (69% <strong>of</strong> eligible<strong>patients</strong>). 13 The first SSNAP acute organisationalaudit found that 95% <strong>of</strong> <strong>patients</strong> were on a stroke uniton the day <strong>of</strong> the audit. However, only about 50%<strong>of</strong> <strong>patients</strong> are admitted directly to such a unit.Sixty-six per cent <strong>of</strong> services provide early supporteddischarge, but community rehabilitation remainsunder-developed. 3258 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Stroke medicineResearchStroke medicine is founded on an increasing evidencebase <strong>of</strong> high-quality international randomisedcontrolled trials and was represented early in theCochrane Collaboration (www.cochrane.org). TheNational Institute for Health Research Stroke ResearchNetwork (NIHR SRN) is one <strong>of</strong> the five main UKclinical research networks (www.uksrn.ac.uk).Specialty guidelines, audits andquality toolsSpecialty guidelines, audits and quality tools arepresented in Box 2.Regional and national workStroke <strong>physicians</strong> work <strong>with</strong>in local clinical networks.Many are involved in the RCP Stroke Programme(Clinical Effectiveness and Evaluation Unit, RCP), theIntercollegiate Stroke Working Party (ICSWP, RCP),and <strong>with</strong> BASP and the NIHR SRN. Current stroke<strong>physicians</strong> are the founder members <strong>of</strong> a new nationalspecialty and continue to work together to developnational service specifications, deliver integratedservices and train future specialists.6 Clinical work <strong>of</strong> consultantsHow a specialist works in this specialty<strong>Consultant</strong> stroke physicans are expected to providedaily assessment <strong>of</strong> new confirmed and suspected strokeand TIA <strong>patients</strong>, including at weekends and bankholidays. Weekly acute and rehabilitation MDTmeetings and twice-weekly ward rounds <strong>of</strong>rehabilitation <strong>patients</strong> are specified. 4Outpatient reivew <strong>of</strong> high-risk TIA <strong>patients</strong> <strong>with</strong>in24 hours and low-risk TIA <strong>patients</strong> <strong>with</strong>in 7 days, and atleast two outpatient review opportunities afterdischarge from a stroke unit, must be provided. Strokespecialists will participate in clinics for spasticity, painand other stroke-related complications.Specialist on callTwenty-four-hour availability <strong>of</strong> an experienced strokephysician for diagnosis and opinion on thrombolysistreatment is mandatory. Few hospitals currently havesufficient experienced consultants <strong>with</strong>in stroke/neurology to provide cover <strong>with</strong>in the EuropeanWorking Time Directive criteria. Hyperacute centresand telemedicine are possible methods <strong>of</strong> achieving a24-hour service.Other specialist activity including activitiesbeyond the local servicesMany stroke <strong>physicians</strong> play an active role in provision<strong>of</strong> tertiary services, research and service development(see above).7 Opportunities for integrated careThe NICE Quality standard for stroke 14 requires thatstroke services are commissioned from and coordinatedacross all relevant agencies to encompass the wholestroke pathway.8 Workforce requirements for the specialtyClinical developments in UK stroke services haveovertaken the specialist resource needed to supportthem. Using nationally approved clinical standards, it iscalculated that 20 direct clinical care (DCC) programmedactivities (PAs) are required to support a serviceadmitting 500 <strong>patients</strong> per year (approximately 300,000population). A population <strong>of</strong> 60 million requires 2,800DCC PAs from stroke specialists. This is equivalent to350 whole-time equivalent (WTE) consultants.However, (RCP) census data indicate that most stroke<strong>physicians</strong> also provide input into another specialty(www.rcplondon.ac.uk/resources). It is acknowledgedthat some aspects <strong>of</strong> stroke care are currently providedby consultants who are not stroke specialists accordingto BASP criteria. Allowing for such subspecialistsupport, it is calculated that the stroke specialistshortfall is currently 163 posts, ie 513 stroke specialistsare required in the UK. In 2011, 40 stroke trainees wereexpected to complete specialist training by 2014.BASP recommended that an extra 30 stroke medicinetrainee places are created per year in the UK for the next4years. 49 <strong>Consultant</strong> work programme/specimenjob planStroke specialists should provide a mimum <strong>of</strong> 5 PAs intostrokecare,usually4DCCPAsand1SPA.Theremaining 5 PAs can support a parent specialty.However, consultants may provide more or less timethan this into stroke care, eg a full-time stroke specialistcould provide 8 DCC PAs and 2 SPAs but would notprovide any input into a parent specialty. 4 For thepurposes <strong>of</strong> this example it is assumed that a 1.0 WTEstroke consultant provides 2.5 DCC PAs into the parentspeciality (Table 1).C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 259


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>Table 1 Specimen job plan for a consultant stroke physicianActivityPAsAcute stroke unit (ASU) ward rounds (7-day service) 1ASU MDT meetings/relatives clinics or meetings 0.25Neuroradiology meeting 0.5Neurovascular clinic (7-day service) 1.25Rehabilitation stroke unit (RSU) ward rounds 1RSU MDT/relatives clinic or meetings 0.5On-call for stroke/TIA/thrombolysis (24-hour service) 1Direct clinical care (DCC) stroke 5.5DCC parent specialty 2.5Supporting pr<strong>of</strong>essional activities (SPAs) 2.0Total PAs 10In this example, a total <strong>of</strong> 20 DCC PAs are needed to support a stroke service.PAs for each activity are as follows:Hyperacute/Acute stroke service: 10.0Rehabilitation stroke service: 2.5Out<strong>patients</strong> including 7-day neurovascular service: 7.5Depending on the amount <strong>of</strong> work in parent specialties, between 4 and 8 stroke consultants are needed in this hospital (maximumon-call frequency 1:4).The British Association <strong>of</strong> Stroke Physicians (BASP) have produced a template for the amount <strong>of</strong> stroke consultant sessions neededaccording to the size <strong>of</strong> the service and the amount <strong>of</strong> work done in parent specialties. 4MDT = multidisciplinary meeting; TIA = transient ischaemic attack.10 Key priorities for commissionersThe key priorities listed below are adapted from NICE’sQuality standard for stroke. 101 People seen by ambulance staff outside hospitalshould be screened using a validated tool, todiagnose stroke or TIA, and transferred to aspecialist acute stroke unit <strong>with</strong>in 1 hour.2 Patients <strong>with</strong> acute stroke who meet any <strong>of</strong> theindications for urgent brain imaging should receivethis <strong>with</strong>in 1 hour.3 Patients <strong>with</strong> suspected stroke should be admitteddirectly to a specialist stroke unit and receivethrombolysis if clinically indicated.4 Patients <strong>with</strong> acute stroke should have theirswallowing screened <strong>with</strong>in 4 hours <strong>of</strong> admissionby a specially trained pr<strong>of</strong>essional before beinggivenoralfood,fluidormedication,andhaveaplan for the provision <strong>of</strong> adequate nutrition.5 Patients <strong>with</strong> acute stroke should be assessed andmanaged by stroke nursing staff and at least onemember <strong>of</strong> the specialist rehabilitation team <strong>with</strong>in24 hours <strong>of</strong> admission, and by all relevant members<strong>of</strong> the team <strong>with</strong>in 72 hours. Documentedmultidisciplinary goals should be agreed <strong>with</strong>in 5days.6 Patients who need ongoing inpatient rehabilitationshould be treated in a specialist strokerehabilitation unit.7 Patients should be <strong>of</strong>fered a minimum <strong>of</strong>45 minutes <strong>of</strong> each active therapy that is required,for a minimum <strong>of</strong> 5 days a week.8 Patients who have continued loss <strong>of</strong> bladder controlafter 2 weeks should be reassessed to identify thecause and have a treatment plan involving bothpatient and carers.9 All <strong>patients</strong> should be screened <strong>with</strong>in 6 weeks,using a validated tool, to identify mooddisturbance and cognitive impairment.260 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


2 Specialties Stroke medicine10 Patients discharged from hospital <strong>with</strong> residualstroke-related problems should be followed up<strong>with</strong>in 72 hours by specialist stroke rehabilitationservices.11 Carers should be provided <strong>with</strong> a named point <strong>of</strong>contact for stroke information, writteninformation about the patient’s diagnosis andmanagement plan, and practical training to enablethem to provide care.References1 National Audit Office. Progress in improving stroke care.London: NAO, 2010.2 British Association <strong>of</strong> Stroke Physicians. Definitions <strong>of</strong> astroke specialist physician. London: BASP, 2011.3 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians, Clinical Effectiveness andEvaluation Unit on behalf <strong>of</strong> the Intercollegiate StrokeWorking Party. Sentinel Stroke National AuditProgramme, SSNAP. Acute organisational audit report.London: RCP, 2012.4 British Association <strong>of</strong> Stroke Physicians. Meeting thefuture challenge <strong>of</strong> stroke. Stroke medicine consultantworkforce requirements 2011–2015. London: BASP, 2011.5 National Institute for Health and Care Excellence. Stroke:national clinical guideline for diagnosis and initialmanagement <strong>of</strong> acute stroke and transient ischaemic attack(TIA). London: NICE, 2008.6 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. National clinical guideline forstroke, 4th edn. London: RCP, 2012.7 Department <strong>of</strong> Health. National stroke strategy. London:DH, 2007.8 World Health Organization. International classification <strong>of</strong>functioning, disability and health: ICF. Geneva:WHO,2001.9 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. National sentinel stroke audit2010. London: RCP, 2010.10 Department <strong>of</strong> Health. General Medical Services (GMS)contract. London: DH, 2003.11 Department <strong>of</strong> Health. NHS outcomes framework2013–14. London: DH, 2012.12 NHS Commissioning Board. Clinical CommissioningGroups Outcomes Indicators Set 2013–14. London: DH,2012.13 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians, Clinical Effectiveness andEvaluation Unit on behalf <strong>of</strong> the Intercollegiate StrokeWorking Party. Stroke Improvement National AuditProgramme (SINAP), 6th quarterly public report.London: RCP, 2012.14 National Institute for Health and Care Excellence.Quality standard for stroke. London: NICE, 2010.15 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Stroke in childhood: clinicalguidelines for diagnosis, management and rehabilitation.London: RCP, 2004.16 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. UK audit <strong>of</strong> vascular surgicalservices and carotid endarterectomy. London: RCP, 2010.17 Department <strong>of</strong> Health. National service framework forolder people. London: DH, 2001.18 Department <strong>of</strong> Health. National service framework forlong term conditions. London: DH, 2005.19 National Audit Office. Reducing brain damage: fasteraccess to better stroke care. London: NAO, 2005.20 Boyle R. Improving stroke services: a guide forcommissioners. London: DH, 2006.21 Welsh Assembly Government. Welsh Health Circulars 058and 082. Cardiff: Welsh Assembly Government, 2007.22 Department <strong>of</strong> Health, Social Services and Public Safety.Improving Stroke Services in Northern Ireland.Belfast:DHSSPS, 2008.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 261


3 Supporting the delivery <strong>of</strong> high-quality care3 The <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians:supporting the delivery <strong>of</strong> high-quality careThe <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians (RCP) supportsfellows and members and the organisations and teamsin which they work to improve the quality <strong>of</strong> clinicalcare that they deliver to <strong>patients</strong>. This is achieved ina number <strong>of</strong> ways: medical training and examinations;education and training programmes; developingclinical guidelines; conducting national comparativeaudits; facilitating data and informatics improvements;undertaking invited service reviews; undertaking qualityimprovement projects; and supporting the membershippreparing for appraisal and revalidation. The RCPalso supports the appointment process for consultant<strong>physicians</strong>, to ensure that the training and experienceare adequate to allow the doctor to practise unsupervised.Support is given to <strong>physicians</strong> who work overseas,through the International Office, and we sharethe quality improvement methodology and educationalexcellence <strong>with</strong> colleagues in other countries.The RCP is also a resource for other organisations, both<strong>with</strong>in and outside the NHS, providing experience andexpertise in improving the quality <strong>of</strong> care.The RCP’s A strategy for quality sets out the domains <strong>of</strong>quality: safety, patient experience, effectiveness, equity,efficiency, timeliness and sustainability. 1Setting standards, measuring standards andcontinuously improving, in ongoing repeated cycles arethebasis<strong>of</strong>theapproach–representedpictoriallyby the quality spiral (see www.rcplondon.ac.uk andsee Fig 2).Information about all the RCP departments and theinfrastructure to support the work <strong>of</strong> the RCP is foundon the website (www.rcplondon.ac.uk).RCP activity has been designed to encourage andsupport <strong>physicians</strong> to evaluate and improve theirclinical practice and improve patient care. Physiciansare able to draw on resources from the RCP at all stages<strong>of</strong> the ‘quality spiral’.Specific details <strong>of</strong> each <strong>of</strong> the programmes the RCP hasdeveloped in support <strong>of</strong> quality improvement areoutlined below.Patient Involvement UnitThe Patient Involvement Unit encourages and promotespatient, carer and public involvement in RCP activities.It does this through the Patient and Carer InvolvementSteering Group and the Patient and Carer Network,ensuring that the patient perspective is included in allRCP policies and decisions.Shared Decision Making/supportedself-management by <strong>patients</strong>As more <strong>patients</strong> have long-term conditions, and <strong>of</strong>tenmore than one, they need to be supported to undertakebetter self-management <strong>of</strong> their conditions. Also,decisions about their care need to be made inpartnership <strong>with</strong> the health pr<strong>of</strong>essional. The RCP istaking forward this agenda, and has appointed a clinicalfellow in Shared Decision Making to work <strong>with</strong>members and fellows and the specialist societies.Education and trainingEducation is a core function <strong>of</strong> the RCP and it delivers awide range <strong>of</strong> programmes for <strong>physicians</strong> <strong>of</strong> all grades.The programmes are continually developed anddesigned to keep <strong>physicians</strong> up to date on all aspects <strong>of</strong>medical education.The Education Department leads in the development <strong>of</strong>educational policy and initiatives and in the provision<strong>of</strong> services and resources to support the pr<strong>of</strong>essionaldevelopment <strong>of</strong> <strong>physicians</strong>.These include the organisation and delivery <strong>of</strong>educational programmes, the production <strong>of</strong> multimediamaterial, accreditation <strong>of</strong> continuing pr<strong>of</strong>essionaldevelopment (CPD) events, the provision <strong>of</strong> access to,C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 263


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>and training in, the use <strong>of</strong> educational resources, andthe provision <strong>of</strong> expertise through consultancynationally and internationally.The Department provides consultancy and projectsupport to the Joint <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> PhysiciansTraining Board (JRCPTB) and to other colleges andfaculties in relation to the development <strong>of</strong> curricula,assessment strategies and workplace-based assessmentmethods.Educational programmesThe Education Department delivers a full range <strong>of</strong>programmes for doctors <strong>of</strong> all grades and specialties.Our Doctors as Educators Programme <strong>of</strong>fers 1- and2-day workshops, which include topics such as teachingskills, medical leadership, appraisal, assessment andeducational supervision skills. We <strong>of</strong>fer two RCPaccreditations: the RCP Educator accreditation and theRCP Educational Supervisors accreditation. We also<strong>of</strong>fer two university-accredited postgraduateprogrammes – a Masters in Medical Education and aMasters in Medical Leadership. In addition to theseprogrammes the Education Department <strong>of</strong>fers bespokein-house training, as well as programmes specifically fornew consultants and junior doctors.Continuing pr<strong>of</strong>essional developmentContinuing pr<strong>of</strong>essional development is the preferredterm in the UK for continuing educationand pr<strong>of</strong>essional development after the completion<strong>of</strong> training. CPD encompasses both continuingmedical education (CME) and the wider range <strong>of</strong>pr<strong>of</strong>essional activities that are required for a doctorto practise medicine. CPD may therefore bedefined as:a continuing learning process, outside formalundergraduate and postgraduate training, whichenables doctors to maintain and improve theirperformance across all areas <strong>of</strong> their practice throughthe development <strong>of</strong> knowledge, skills, attitudes andbehaviours.The Federation <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong>the UK provides an online CPD scheme for <strong>physicians</strong>.Live and distance-learning activities are approved for‘external’ CPD if they meet educational quality criteria.Approved activities are placed on a database accessibleto scheme members. Activities are recorded in anindividual’s electronic CPD diary and may be matchedagainst specific learning objectives. Credits aregained for an activity once a structured reflection iscompleted.Jerwood Medical Education Resource CentreThe Jerwood Medical Education Resource Centre,which forms part <strong>of</strong> the RCP’s library services, wasopened in 2002 and holds a specialist collection <strong>of</strong> over6,000 items including books, journals and CD-ROMs.The collection supplements the educational coursescoordinated by the RCP and provides <strong>physicians</strong> <strong>with</strong>access to comprehensive resources and materials tosupport their CPD and teaching responsibilities. Fellowsand subscribing members are entitled to borrowmaterials from the collection and can also apply foraccess to an extensive selection <strong>of</strong> online databases andelectronic journals. Additional services include adetailed information and literature search service,database training and subject guidance.Curriculum and assessment developmentEducationalists from the Education Departmentregularly work <strong>with</strong> JRCPTB and the specialty advisorycommittees to provide expert advice on and practicalsupport for the development <strong>of</strong> curricula andassessment systems. The Department providesconsultancy services on curriculum development andassessment to other colleges and faculties bothnationally and internationally. The EducationDepartment has led the development, piloting andvalidation <strong>of</strong> workplace-based assessment methods fortrainees and is currently piloting a new method <strong>of</strong>assessing leadership competencies for trainees. TheDepartment is also project managing the developmentand implementation <strong>of</strong> a knowledge-based assessmentsystem for small specialties.RCP educational consultancyThe RCP educational consultancy works <strong>with</strong> medicalorganisations – both in the UK and internationally – t<strong>of</strong>acilitate the most effective solutions to a range <strong>of</strong>challenging educational and training issues which themodern medical pr<strong>of</strong>ession faces and then works <strong>with</strong>organisations to implement those solutions successfully.The consultancy has worked in several differentcountries including the USA, Singapore, Sri Lanka,Uganda and Oman, and has supported a number <strong>of</strong>different organisations, from deaneries and teachinghospitals to specialty boards and universities. Theconsultancy <strong>of</strong>fers a range <strong>of</strong> different services,264 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


3 Supporting the delivery <strong>of</strong> high-quality caredependent on the specific needs <strong>of</strong> the organisation,from advisory roles to major curriculum design anddevelopment work.ConferencesThe Conferences Department provides a programme <strong>of</strong>scientific and educational events designed to maintainand improve the clinical practice <strong>of</strong> members, fellowsand other healthcare pr<strong>of</strong>essionals throughout theircareers. It is focused increasingly on providing aresource that fellows and members can use for fulfillingthe educational and development requirements forrevalidation.The annual conferences in advanced, acute and generalmedicine remain the foundation <strong>of</strong> the Department’sactivity. The joint specialty committees are invited topropose subjects for specialist educational eventsaccording to a rolling, predetermined programme, inorder to provide conferences on topics appealing towide, cross-specialty or multidisciplinary audiences.Those selected are ‘joint badged’ <strong>with</strong> the relevantsocieties. The programme <strong>of</strong> events also includesteach-ins and lectures, many <strong>of</strong> which are available as aweb-stream.Delegate interaction, facilitated by means <strong>of</strong> anaudience-response system, is an important component<strong>of</strong> many conferences, <strong>with</strong> the eventual aim <strong>of</strong>developing a generic assessment process, wherebyknowledge gained can be demonstrated and logged intoRCP-based delegates’ electronic CPD records. Again,this would be invaluable in helping members andfellows to fulfil their requirements for revalidation.The Department also provides support for theadministration <strong>of</strong> the RCP trust funds and the award <strong>of</strong>many prestigious fellowships, prizes and lectureships.Increasingly, these are awarded in conjunction <strong>with</strong>external bodies, eg Medical Research Council (MRC)and the Dunhill Medical Trust, to increase the range andquality <strong>of</strong> applications, to attract matched funding andto ensure a rigorous and fair method <strong>of</strong> evaluation.Specialty recruitmentIn 2007, coinciding <strong>with</strong> Modernising Medical Careers,the Medical Training and Application Service (MTAS)took on coordinated recruitment. This venture was notsuccessful so the RCP was asked to coordinate coremedical training (CMT) recruitment in 2009. This wasdone by a small team <strong>with</strong>in the Education Departmentassisted by clinical leads. Following the success <strong>of</strong> thisRCP-run process, five ST3 specialties were added to theprocess in 2010, and the Specialty Recruitment Officenow runs recruitment for CMT and 16 medical ST3specialties.Recruitment is traditionally fraught and contentious sothe RCP team concentrated on prompt delivery <strong>of</strong> ahigh-quality streamlined process. Extensiveconsultation and communication <strong>with</strong> stakeholders wasundertaken, particularly <strong>with</strong> the trainees and cliniciansinvolved as well as the deaneries who continue to deliverrecruitment for their own localities. The recruitmentwebsites, www.CMTrecruitment.org.uk andwww.ST3recruitment.org.uk, are key resources, backedup by a help desk, extensive guides and trainingmaterials and question banks. The RCP service isregarded as one <strong>of</strong> the gold standards in recruitment.Coordinated recruitment is now embedded in mosttraining programmes, and the RCP has played a keypart in making this work well for medical specialtyrecruitment. We continue to rely on the cooperation <strong>of</strong>trained <strong>physicians</strong> in assisting <strong>with</strong> the recruitment <strong>of</strong>trainees to their training programmes.ExaminationsThe Membership <strong>of</strong> the <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians(UK) (MRCP(UK)) Diploma is a high-stakes examwhich tests the skills, knowledge and behaviour <strong>of</strong>doctors in training. It has three parts: two writtenpapers that test medical knowledge and judgement, anda clinical component called PACES (PracticalAssessment <strong>of</strong> Clinical Examination Skills). Under therules for the latest UK curriculum, completion <strong>of</strong> theentire three-part examination is a requirement forapplicants seeking specialist training posts (ST3).Internationally, one or more parts <strong>of</strong> the MRCP(UK) isdelivered in 27 countries. The Specialty CertificateExaminations (SCEs) are a relatively new requirementfor specialist <strong>physicians</strong> in the UK and they are gainingrecognition internationally. SCEs have been developedin close collaboration <strong>with</strong> the specialist societies andthey are demanding assessments for <strong>physicians</strong> nearingthe end <strong>of</strong> specialist training, which test knowledge atan advanced level. They consist <strong>of</strong> 200 ‘best <strong>of</strong> five’multiple-choice questions and are administered via acomputerised system at test centres around the world.By the end <strong>of</strong> 2011 a total <strong>of</strong> 12 SCEs had been rolledout. To encourage uptake around the world, we will beC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 265


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>broadening the eligibility criteria, allowing many moreexperienced trainees the opportunity to sit the SCEs.Joint <strong>Royal</strong> <strong>College</strong>s Postgraduate Training BoardThe Joint <strong>Royal</strong> <strong>College</strong>s Postgraduate Training Board(JRCPTB) (www.jrcptb.org.uk) is responsible to theFederation <strong>of</strong> <strong>Royal</strong> <strong>College</strong>s <strong>of</strong> Physicians <strong>of</strong> the UK forcarrying out the functions relating to the supervision <strong>of</strong>medical training as devolved to it by the GMC and byarrangement <strong>with</strong> any other organisations as may berequired. The policy directions <strong>of</strong> the GMC, MedicalEducation England and the equivalent organisations inthe devolved nations remain the principal drivers forthe JRCPTB’s operations. Its main functions, through asystem <strong>of</strong> specialist and core medical trainingcommittees, are to:Fig 2 The RCP quality spiral monitor individual trainees’ progress throughspecialist training and to make recommendationsfor the award <strong>of</strong> Certificate <strong>of</strong> Completion <strong>of</strong>Training (CCT); this entails:– the enrolment <strong>of</strong> all trainees (national trainingnumbers (NTNs) and other categories)– maintaining a database <strong>of</strong> all trainees andmonitoring their progress– contributing to the penultimate-year assessmentand the Annual Review <strong>of</strong> CompetenceProgression (ARCP) process– signing <strong>of</strong>f completion <strong>of</strong> training in concert <strong>with</strong>programme directors and postgraduate deaneries undertake the evaluation <strong>of</strong> applications forCertificates <strong>of</strong> Eligibility for Specialist Registration(CESR) and make recommendations on each one develop and arrange the ongoing review <strong>of</strong> generic,core and specialist training curricula and assessmentstrategies (including examinations) develop efficient processes, <strong>working</strong> <strong>with</strong> thepostgraduate deans and college representativeslocally, for the quality management (ensuringdelivery) <strong>of</strong> physician training as stipulated incurricula and assessment strategies.Leadership developmentIn 2011, a new intercollegiate Faculty <strong>of</strong> MedicalLeadership was established to support those <strong>physicians</strong>who are undertaking specific leadership roles such asclinical or medical directors and will develop as aresource for developing leadership skills for the medicalpr<strong>of</strong>ession as a whole. The RCP will play a full part inthe future development <strong>of</strong> the Faculty.Clinical standards at the RCP: definingcare, measuring care, improvingcare for <strong>patients</strong>The vision <strong>of</strong> the Clinical Standards Department is toimprove patient care by the setting, monitoring andimplementation <strong>of</strong> clinical standards (Fig 2).The intention <strong>of</strong> the Clinical Standards Departmentis to provide leadership and support to RCP fellows,members and the teams and organisations inwhich they work to deliver the highest standards<strong>of</strong> clinical practice and so the highest standards inpatient care. The approaches used to deliver thisintent are: clinical management guidelines national comparative clinical audit implementation and dissemination, sharing <strong>of</strong> bestpractice quality improvement projects revalidation and appraisal accreditation health informatics patient safety.Our style <strong>of</strong> <strong>working</strong> is that <strong>of</strong> multipr<strong>of</strong>essionalcollaboration, keeping the patient at the heart <strong>of</strong> ourwork. Active front-line clinicians direct the workprogramme supported by health service researchers,project managers, statisticians and health economists.We work closely <strong>with</strong> those national bodies relevant tosupporting delivery <strong>of</strong> high-quality patient care in theNHS such as the Department <strong>of</strong> Health, national266 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


3 Supporting the delivery <strong>of</strong> high-quality careclinical leads, the National Institute for Health and CareExcellence (NICE), the Healthcare QualityImprovement Partnership (HQIP), the Care QualityCommission (CQC), Health Improvement Scotland,the National Leadership and Innovation Agency forHealthcare in Wales, specialist societies, other royalcolleges and patient groups.Clinical management guidelinesTo provide optimal patient care it is necessary to knowwhat constitutes optimal care. Determining this can bedifficult, increasingly so as medicine becomes morecomplex, more treatments become available and theassociated scientific literature increases. One way <strong>of</strong>helping clinicians to manage their <strong>patients</strong> effectively inthe face <strong>of</strong> information overload is the production <strong>of</strong>clinical guidelines. The primary purpose <strong>of</strong> a guidelineis to set out recommendations for the most appropriatemanagement <strong>of</strong> <strong>patients</strong> <strong>with</strong> a specified condition.Therefore, guidelines should be as clear and direct aspossible. However, a patient <strong>with</strong> an uncomplicated,single pathology is something <strong>of</strong> a rarity. Concerns havebeen expressed that an over-reliance on guidelines willproduce doctors who cease to think through theirpractice and make decisions. This is no more anecessary consequence <strong>of</strong> relying on guidelines than <strong>of</strong>using textbooks or lectures for medical education.Recommendations must be applied to individual<strong>patients</strong> <strong>with</strong> their particular preferences and theirdifferent comorbidities. But it is still important to havea clear, basic foundation from which to build, andguidelines provide this.Guidelines should inform routine patient care andwhile it is reasonable to be at variance from standardguidance, as determined by a patient’s circumstances, itis prudent to document why the alternative course wastaken. This leads to the secondary function <strong>of</strong>guidelines – to provide a basis for the audit <strong>of</strong> thequality <strong>of</strong> patient care. Recommendations <strong>with</strong>inguidelines are an important source <strong>of</strong> audit criteria, andindeed many guidelines encourage this by suggestingappropriate topics.Producing guidelinesClinical guidelines are developed using a variety <strong>of</strong>methodologies. One <strong>of</strong> the most rigorous approaches isused by the National Clinical Guidelines Centre(www.ncgc.ac.uk).ThecentreishostedattheRCPtodeliver a large and diverse commissioned programmefor NICE. The guidelines have the advantage <strong>of</strong>incorporating both clinical and cost-effectivenessevidence. Another common methodology is the ScottishIntercollegiate Guidelines Network (SIGN) approach,which is <strong>of</strong>ten adopted by the specialist societies as it isless resource intensive and is consistent <strong>with</strong> theAppraisal <strong>of</strong> Guidelines Research and Evaluation(AGREE) collaboration (www.agreecollaboration.org),an international collaboration quality assuringguideline methodology. This methodology is also usedfor the development <strong>of</strong> guidelines for occupationalhealth, stroke and in the Concise Guidelines to GoodPractice series.The topics that RCP guidelines cover grow on amonthly basis and can be found on the RCP website(www.rcplondon.ac.uk/resources/clinical-resources).Specialist societies produce excellent guidelines whichare particularly useful sources <strong>of</strong> information on rarertopics that are less likely to be covered by NICE. TheRCP is supporting specialist society guidelines bypublishing the Concise Guidelines series in ClinicalMedicine and in booklet form.National comparative clinical auditDonabedian defined quality <strong>of</strong> care as ‘the degree <strong>of</strong>conformance to, or deviation from, normativebehavior’. 2 Brook and Kosec<strong>of</strong>f more succinctly definedit as ‘doing the right things . . . well’. 3 In 2010, followinga review <strong>of</strong> the literature and a consultation exercise, theRCP developed its own definition <strong>of</strong> quality. Itcomprises seven domains: safety, <strong>patients</strong>’ experience,effectiveness, equity, efficiency, timeliness andsustainability. All definitions imply the need forstandards – ‘normative behaviour’ and ‘doing the rightthings’ – and the need for measurement <strong>of</strong> practice, allkey elements <strong>of</strong> clinical audit.Clinical audit is conventionally considered as a cycle <strong>of</strong>quality improvement that involves measurement <strong>of</strong> theeffectiveness <strong>of</strong> healthcare against agreed and provenstandards for high quality, and taking action to bringpractice in line <strong>with</strong> these standards so as toimprove the quality <strong>of</strong> care and health outcomes.Detailed advice for carrying out clinical audit can befound in New principles <strong>of</strong> best practice in clinical audit 4and Local clinical audit: handbook for <strong>physicians</strong> (HQIP,2010). 5Recommendations include the following:Determining standards for practice: increasinglystandards are based on evidence or derived from soundC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 267


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>consensus methods. Important sources <strong>of</strong> guidelinesand standards that form the basis <strong>of</strong> audit include NICEand SIGN, policy guidance such as national serviceframeworks (NSFs), commissioning frameworks orclinical strategies, and clinical guidelines from specialistsocieties, eg the British Thoracic Society (BTS)guideline Emergency oxygen use in adult <strong>patients</strong>. 6Measuring practice: clinical audit is a multipr<strong>of</strong>essionalactivity that should reflect the service provided by theclinical team. Measurement <strong>of</strong> practice is not simple.Careful consideration has to be given to the patientgroups to be audited, the audit criteria to be used, themethods for identifying <strong>patients</strong>, and for dataextraction, data collation and analysis. Cliniciansshould work closely <strong>with</strong> clinical audit departments toensure that the method is sound and thus time investedin clinical audit results in useful outputs. Clinical auditdepartments are invaluable in providing support andadvice, and ensuring that results and actions arereported through NHS governance processes to theNHS Boards. 7Changing practice: the purpose <strong>of</strong> audit is to improvepractice. Unless service improvement is included <strong>with</strong>inthe process, it is meaningless. The results from an auditshould be followed up <strong>with</strong> action plans forimprovement, and in order to achieve change it isimportant that there is close cooperation betweenclinicians and managers.Re-measuring practice over a time series enables trendsto be established and show whether progress has beenmade. Clinicians need to see clinical audit having animpact on service development if it is to establishsustainable change in practice.Clinical audit has many potential uses in clinicalpractice, in the following areas: Improving the quality <strong>of</strong> care: the audit topic must beimportant and <strong>of</strong> interest to the clinician. Theresults <strong>of</strong> audits must be reviewed <strong>with</strong>in teams anddepartments, and used to inform servicedevelopment and improvement work. Repeat auditsmust be carried out to demonstrate whether or notprogress is being made. Audit as routine practice: the increasing development<strong>of</strong> information technology <strong>with</strong>in the NHS providesthe opportunity for routine clinical data gathering t<strong>of</strong>eed into audit processes. Accessing the patient’s perspective: increasinglyclinical audit is developing to ensure that thepatient’s perspective is included in assessing thequality <strong>of</strong> service provided. Training: clinical audit provides an opportunity tolearn the principles <strong>of</strong> literature searching andcritical appraisal as well as scrutinising careprovision through data collection and subsequentchange-management processes. An understanding<strong>of</strong> these principles underpins informed analysis <strong>of</strong>the literature as well as the methods for improvingthe quality <strong>of</strong> care. Revalidation: clinicians participate in audit anddemonstrate that they have reflected on theoutcomes <strong>of</strong> audit.Clinical audit and specialist societiesSpecialist societies have the potential to make a greatcontribution to audit. Many societies already developguidelines for practice, the majority <strong>of</strong> which areamenable to audit.Through their existing contacts <strong>with</strong> all medicaldepartments throughout the UK, and for someinternationally, societies are in a strong position tocoordinate multicentre audit projects using agreedstandards and audit criteria. Such a role can enable therapid collection <strong>of</strong> powerful data for use both at a locallevel and for benchmarking between sites.Societies are very well placed to disseminate findings –through their publications and at regional andnational meetings. Such feedback can facilitate thesharing <strong>of</strong> best practice while providing a forum fordebating how the quality <strong>of</strong> clinical practice can beimproved.Dissemination and implementation(sharing best practice)The Clinical Standards Department’s approach todelivering quality improvement projects ensuresinteraction <strong>with</strong> key stakeholders throughout projectimplementation. This establishes routes for activecommunication and naturally facilitates dissemination<strong>of</strong> information and findings directly to our keystakeholders. The RCP works to embed a culture <strong>of</strong>recognising the importance <strong>of</strong> these activities andsharing ideas and mechanisms that are tried and tested;however, we recognise that we do not know eachorganisation’s or clinical team’s circumstances.Dissemination and implementation are thereforeinitiated both locally and nationally.268 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


3 Supporting the delivery <strong>of</strong> high-quality careWe disseminate via targeted reports and communicationsto the most involved audiences, and host nationalconferences and regional workshops. We provideslide sets which can be edited <strong>with</strong> local data to makedissemination as simple as possible and to encouragean accurate and consistent message. Broader audiencesare targeted through press activity, RCP publications,and presentations at regional and national conferences,workshops and meetings, along <strong>with</strong> numerousacademic papers published in peer-reviewed journals.Implementation activity depends very much on theproject topic and the specific findings orrecommendations. Generic approaches include use <strong>of</strong>conference sessions and regional workshops to discussfindings and application <strong>of</strong> recommendations in detail,gathering feedback (via anonymous voting, discussion,focus groups) and creating action plans for local teams.Peer or expert reviews are <strong>of</strong>ten <strong>of</strong>fered.The focus is always on the evidence base, bespokedatasets and identification <strong>of</strong> what will work inindividual circumstances. Audit data are widely shared,in various formats, to support patient choice initiatives,regulatory activities, such as the Care QualityCommission’s Quality risk pr<strong>of</strong>iles, 8 policydevelopment, for example, the strategy for services forchronic obstructive pulmonary disease (COPD) inEngland, 9 and evaluation <strong>of</strong> public expenditure such asthe National Audit Office report, Progress in improvingstroke care. 10Quality improvement projectsIn line <strong>with</strong> the key objectives <strong>of</strong> the white paper inEngland, Equity and excellence: liberating the NHS, 11and its own A strategy for quality, 1 the RCP manages anumber <strong>of</strong> innovative projects that aim to driveimprovements in specific aspects <strong>of</strong> healthcare wheredeficiencies or variations are identified through nationalclinical audit. Working in collaboration <strong>with</strong> specialistsocieties and patient groups to plan projects, and closely<strong>with</strong> clinical teams at the front line, a number <strong>of</strong> qualityimprovement techniques are implemented to supportefforts to improve the patient experience and outcomes<strong>of</strong> healthcare services. 12AccreditationAccreditation is a self-assessment and external peerassessment evaluation process used to assess accuratelya service’s level <strong>of</strong> performance in relation to establishedstandards. Healthcare providers are required to produceevidence to demonstrate their compliance <strong>with</strong> thestandards. Accreditation is seen as a ‘badge <strong>of</strong> quality’for a healthcare provider and is important tocommissioners and <strong>patients</strong> alike.The RCP’s accreditation schemes have at their heart theHQIP-approach to pr<strong>of</strong>essionally led clinical serviceaccreditation. They aim to improve the quality, safetyand outcomes <strong>of</strong> healthcare, the patient experience andservice delivery. The schemes are pr<strong>of</strong>essionally led bymultidisciplinary teams. They are supportive <strong>of</strong>healthcare services and as such include training daysand facilitate sharing <strong>of</strong> best practice among teams. Akey feature is the self-assessment and improvementtools available to services for them to measure their ownperformance in relation to the standards before anaccreditation assessment takes place. If a healthcareprovider does not meet the standards at the time <strong>of</strong> theassessment, the assessors recommend key actions andwork <strong>with</strong> the service to support them in gainingaccreditation.Accreditation standards are reviewed periodically and inthis way are used as a driver for quality improvement asthe required level <strong>of</strong> quality is raised over time. Workingin partnership <strong>with</strong> our clinical audit colleagues is key, asconducting and reviewing clinical audits is an importantpart <strong>of</strong> accreditation criteria for the various schemes.Health informaticsGood quality medical record keeping is essential forgood quality care and the wide variation in the structureand content <strong>of</strong> medical notes presents a major problemfor the development <strong>of</strong> electronic healthcare. Thestandardisation <strong>of</strong> the administrative, demographic andclinical content <strong>of</strong> health records is needed to ensure unambiguousrecording, safe communication and reliableintegration <strong>of</strong> data held in different record systems. Itis also essential to ensure that any analysis <strong>of</strong> aggregateddata is valid and reliable. The need for informationstandards to support both safe clinical care and clinicalresearch has been confirmed by many reports in thelast few years. 9–17 If clinical research is to be effectivelyintegrated into the work <strong>of</strong> the NHS, standardisation<strong>of</strong> clinical information recording is required.In brief, information record keeping standards areneeded to ensure: appropriate data capture, in both structured formand free text, in different clinical and researchcontexts and locations valid and reproducible data extraction intosummary recordsC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 269


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong> valid and safe inter-operability between systemswhen communicating or integrating patient dataheld in different systems – a reduction in ambiguitywill bring benefits for patient safety meaningful, valid analysis when data are aggregatedor analysed retrospectively to inform servicedevelopment, performance monitoring, activityanalysis and research common language for describing clinical researchquestions, and research commissioning, registration,management and reporting, which integrates <strong>with</strong>terminologies and definitions used in clinicalpractice.Patient safetyThe RCP has established a patient safety committee tolook at safety issues that arise in the practice <strong>of</strong> themedical specialties. This will work <strong>with</strong> the <strong>patients</strong>afety initiatives in the devolved nations, includingNHS England. The National Reporting and LearningService, now at Imperial <strong>College</strong>, London, is a source <strong>of</strong>data for learning that can then be disseminated to ourmembers and fellows. We will work in partnership <strong>with</strong>other disciplines and external stakeholders and willfurther education in safety issues for our members andfellows.Revalidation and appraisalRevalidation is the process whereby doctors have todemonstrate on a regular basis that they are up to dateand fit to practise. This is achieved through a process <strong>of</strong>formal annual appraisal, where a doctor producessupporting information to demonstrate that they havemettherequirementssetoutintheGoodMedicalPractice (GMP) framework for revalidation set by theGeneral Medical Council (GMC) (www.gmc-uk.org).Doctors will be revalidated every 5 years in order toretain their licence. This will be based on the successfuloutcome <strong>of</strong> five annual appraisals, a multi-sourcefeedback, CPD and participation in audit. Arecommendation for revalidation will then be made tothe GMC by a responsible <strong>of</strong>ficer. Revalidation startedin late 2012.Although there has been suggestion that revalidation isa means <strong>of</strong> identifying ‘bad doctors’, the RCP is keen toensure that revalidation is a vehicle for achieving,maintaining and improving the quality <strong>of</strong> all <strong>physicians</strong>’practice and provision <strong>of</strong> care. Revalidation should be ameans <strong>of</strong> helping to identify areas for improvement atan early stage, and for ensuring that there are clearsupport mechanisms available. Revalidation will workin parallel to existing clinical governance andperformance management systems, but is very muchabout the individual doctor’s development.TheRCP’saimistoshapeaclearrevalidationprocessfor <strong>physicians</strong>, but to ensure that this process is part <strong>of</strong> aconsistent and equitable system for specialties that allcolleges and faculties support, and is also aligned <strong>with</strong>the generic requirements <strong>of</strong> the GMC and RevalidationSupport Team (RST). We are <strong>working</strong> closely <strong>with</strong> theAcademy <strong>of</strong> Medical <strong>Royal</strong> <strong>College</strong>s, individual colleges,and other key stakeholders to achieve this.The RCP is involved in a number <strong>of</strong> activities. We: undertook a national pathfinder pilot to assess thestrengthened medical appraisal process and theGMC’s GMP framework developed validated multisource feedback (MSF)colleague and patient questionnaires which arecurrently used by different specialties in many trusts.We are now rolling out a specialty-specific version <strong>of</strong>the questionnaire, and we are currently piloting aversion for medical managers developed a personal clinical audit tool (p-cat)which is a simple online tool designed to assistdoctors to capture a high-quality audit, to documentthe process effectively and, importantly forrevalidation, to reflect on their participation and anyresulting change in practice. The output <strong>of</strong> the toolis a summary that can be provided as supportinginformation for appraisal are coordinating a ‘cohort’ to develop an e-systemfor revalidation, which will allow doctors to managetheir supporting information for appraisal. Thesystem will be designed to inter-operate <strong>with</strong>existing college systems such as CPD, and othernational systems as necessary are providing high-quality appraisal training, andresponsible <strong>of</strong>ficer (RO) training developed, on behalf <strong>of</strong> the Academy <strong>of</strong> Medical<strong>Royal</strong> <strong>College</strong>s, consistent specialty guidance forappraisal, and to consider the aspects <strong>of</strong> specialtytraining required for appraisers, those advisingappraisers and ROs.As time goes on, the RCP will provide more detailedongoing guidance to members and fellows to support270 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


3 Supporting the delivery <strong>of</strong> high-quality carethem in revalidation, and a permanent revalidation<strong>of</strong>fice has been established.Regional adviser networkThe RCP maintains a network <strong>of</strong> regional advisers andregional specialty advisers in 19 UK regions. Ten regionshave a dedicated RCP regional <strong>of</strong>fice providing a localpoint <strong>of</strong> contact for our members, supporting the work<strong>of</strong> the regional advisers and <strong>of</strong>fering valuable supportfor RCP activities <strong>with</strong>in the region.Following a review <strong>of</strong> the role <strong>of</strong> regional advisers, theRCP is <strong>working</strong> <strong>with</strong> its local representatives to developpr<strong>of</strong>essional networks that have the capacity tocontribute to service quality improvement. There havebeen a series <strong>of</strong> regional conversations <strong>with</strong> local<strong>physicians</strong> facilitated by the regional advisers. This is anopportunitytoraiseconcernsaswellassharewhathasgone well. The RCP has then fed back those findings tolocal trust chief executives and medical directors. Otherimportant roles for regional advisers may include: developing local educational programmes participating in the local deanery school <strong>of</strong> medicine reviewing and approving job descriptions considering proposals for fellowship advising on clinical excellence awards approving educational events for CME liaising <strong>with</strong> college tutors promoting the hosting <strong>of</strong> MRCP(UK) in the region developing relationships <strong>with</strong> <strong>physicians</strong> in the area,to assist <strong>with</strong> service delivery issues supporting local commissioning/planning processes.Work <strong>with</strong> specialist societiesSpecialist societies work <strong>with</strong> their members to promotehigh-quality care in that particular specialty. The RCPworks <strong>with</strong> the individual societies, using their expertisewhen needed, and meeting <strong>with</strong> them through jointspecialty committees. Some <strong>of</strong> the larger societies send arepresentative to the RCP Council.Working party reportsThe RCP provides guidance to <strong>physicians</strong> and the widerNHS on topics <strong>of</strong> clinical relevance by publishingreports from <strong>working</strong> parties, which are set up as taskand finish groups, to review what is known about asubject, including the patient and public’s perspective,and making recommendations for best practice andfuture policy development. These reports are availableon the RCP website.Workforce issuesThe RCP Medical Workforce Unit (MWU) collects andanalyses information on issues related to humanresources and workload. Data are collected in theannual census on consultant <strong>physicians</strong>, annualspecialty registrar (StR) survey and annual StR census.Data include numbers, demographics, workload andrelevant topical data. The results <strong>of</strong> the consultant andStR census are available online. The unit also performsperiodic surveys <strong>of</strong> other <strong>physicians</strong>, eg specialty andassociate specialists.Data are used to inform discussion <strong>with</strong> the DH (via theCentre for Workforce Intelligence), the medicalspecialties, other colleges and the media. The MWUworks very closely <strong>with</strong> the JRCPTB to ensure thatrecommendations about future StR numbers areaccurate and appropriate.TheMWUhasledtheRCP’sapproachtotheEuropeanWorking Time Directive (EWTD), and has beeninvolved in the development <strong>of</strong> the ‘Hospital at night’system. It has exposed the difficulties and dangers <strong>of</strong>certain rotas and has expressed concern over the balance<strong>of</strong> time juniors spend in training, service work or onemergency duties. It is particularly concerned <strong>with</strong> thecurrent role <strong>of</strong> and issues facing StRs in medicine.It is involved in a range <strong>of</strong> other workforce-relatedprojects including: flexible training for <strong>physicians</strong>;monitoring consultant vacancies; and women inmedicine, particularly as trainee <strong>physicians</strong>. The MWUruns an in-house questionnaire service, which designs,performs and analyses surveys to support RCP activities.The Pr<strong>of</strong>essional Affairs Department manages the RCP’sstatutory and non-statutory role in the appointment <strong>of</strong>consultants and other senior hospital doctors in theNHS. It works <strong>with</strong> NHS trusts and regional advisers inorder to review job descriptions and providenominations <strong>of</strong> consultants to serve on advisoryappointments committees (AACs). Advice is <strong>of</strong>fered tomedical staffing departments regarding ‘good practice’and statutory and non-statutory procedures. An annualC○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 271


<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>report is produced and AAC data made available to theMWU.Invited service reviewsAn invited service review can be requestedby hospital management and fellows or members <strong>of</strong> theRCP when they require independent advice on issues<strong>of</strong> concern in relation to the practice <strong>of</strong> medicine. Thismay be in respect <strong>of</strong> service delivery, patient safety, teamfunctionality, clinical governance or workload issues.This process supports <strong>physicians</strong> and trust managementwhen they feel that the practice <strong>of</strong> good clinicalmedicine is compromised, and forms an importantmethod for protecting patient care and ensuring<strong>patients</strong>afety.Thereportisgiventothecommissioningorganisation, <strong>with</strong> recommendations for improvementand the RCP will <strong>of</strong>fer further support if invited todo so.International OfficeThe International Office supports members and fellows<strong>working</strong> outside the UK, and promotes RCP expertiseand services. It builds relationships <strong>with</strong> keyindividuals, organisations and governments, and takesan advocacy role on global health issues identified bythe RCP. With nearly 20% <strong>of</strong> the RCP’s subscribingmembers and fellows <strong>working</strong> in over 80 countries andin all continents, international relations are vital. TheRCP aims to extend its role to promote high standards<strong>of</strong> healthcare globally by engagement <strong>with</strong> its overseasfellows and members, strategic partners and individualcountries and regions.The key objectives <strong>of</strong> the department include:1 the support <strong>of</strong> medical graduates from outside theUK, who wish to undertake part <strong>of</strong> their training as<strong>physicians</strong> <strong>with</strong>in this country. This involves threeschemes, namely the International SponsorshipScheme, the Clinical Placement Initiative and theInternational Medical Graduate scheme2 overseas partnerships to support postgraduatemedical training. At present these includecommitments in West Africa, <strong>with</strong> the West African<strong>College</strong> <strong>of</strong> Physicians, Sudan, Oman, China and SriLanka. Further international collaborations tosupport postgraduate training are in the planning orearly development stages3 international net<strong>working</strong> <strong>with</strong> key organisations andagencies, including the World Health Organization,overseas universities and governments, the UKDepartment for International Development, andother UK government departments4 support for the international work <strong>of</strong> other RCPdepartments, including Education, the NationalClinical Guidelines Centre, and CorporateCommunications and Publishing.ConclusionThe <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians is involved in manyactivities to set standards, measure standards andimprove standards. The ongoing spiral <strong>of</strong> improvementis a dynamic process. The aim is to ensure that <strong>patients</strong>receive the best care possible and have a goodexperience <strong>of</strong> care. We have begun work looking at theprocesses <strong>of</strong> care – eg how ward rounds are conducted,how the pr<strong>of</strong>essions should better work together andhow to improve communication, particularly betweendoctors and nurses.We recognise that care is delivered <strong>with</strong>in systems, andthat doctors need to work to improve systems <strong>of</strong> care aswell as individual interactions <strong>with</strong> <strong>patients</strong>. This willimprove efficiency, patient experience and patient safety.We are constantly reviewing how doctors perform inwider society and recognise that pr<strong>of</strong>essionalism is alsoa dynamic concept, which changes as society changes.We will continue to develop resources to help doctorswho are members and fellows <strong>of</strong> the RCP to constantlyimprove their practice and to deliver high-quality careto <strong>patients</strong>. Our work also continues to be a resource forproviders <strong>of</strong> care, commissioners, planners, policymakers, <strong>patients</strong> and the public.References1 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. A strategy for quality: 2011and beyond. www.rcplondon.ac.uk/policy/improvinghealthcare/rcp-strategy-for-quality2 Donabedian A. The quality <strong>of</strong> care. How can it bemeasured? JAMA 1988;260:1743–8.3 Brook RH, Kosec<strong>of</strong>f JB. Competition and quality. HealthAffairs 1988;7:150–61.4 Healthcare Quality Improvement Partnership. Newprinciples <strong>of</strong> best practice in clinical audit.London:HQIP,2011.272 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013


3 Supporting the delivery <strong>of</strong> high-quality care5 Potter J, Fuller C, Ferris, M. Local clinical audit: handbookfor <strong>physicians</strong>. London: RCP, 2010.6 BritishThoracicSociety.Guideline for emergency oxygenuse in adult <strong>patients</strong>, 2008. www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Emergency%20Oxygen/Emergency%20oxygen%20guideline/THX-63-Suppl 6.pdf7 Healthcare Quality Improvement Partnership. Clinicalaudit: a simple guide for NHS Board and partners.London: HQIP, 2010.8 Care Quality Commission. Quality risk pr<strong>of</strong>iles. 2011.www.cqc.org.uk/guidanceforpr<strong>of</strong>essionals/nhstrusts/ourmonitoring<strong>of</strong>compliance/qualityandriskpr<strong>of</strong>iles.cfm9 Department <strong>of</strong> Health. Consultation on a strategy forservices for COPD in England. 2010. www.dh.gov.uk/prod consum dh/groups/dh digitalassets/@dh/@en/documents/digitalasset/dh 113279.pdf10 National Audit Office. Department <strong>of</strong> health: progress inimproving stroke care. 2010. www.nao.org.ukpublications/0910/stroke.aspx11 Department <strong>of</strong> Health. Equity and excellence: liberatingthe NHS. London: DH, 2010.12 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. www.rcplondon.ac.uk/resources/results?tid%5B%5D=177&title=&body13 Cr<strong>of</strong>t GP, Williams JG. The RCP information laboratory(iLab): breaking the cycle <strong>of</strong> poor data quality. Clin Med2005;5:47–9.14 Carpenter I, Bridgelal Ram M, Cr<strong>of</strong>t G, Williams J.Medical records and record-keeping standards. Clin Med2007;7:328–31.15 Health Informatics Unit, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians.Hospital activity data – a guide for clinicians. InformationCentre, NHS. London: RCP, 2007. www.ic.nhs.uk/webfiles/Clinical/Hospital Activity Data A Guide forClinicians England.pdf16 Health Informatics Unit, <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Topten tips for coding – a guide for clinical staff. InformationCentre, NHS. www.ic.nhs.uk/webfiles/Clinical/Top TenTips for Coding A Guide for Clinical Staff.pdf17 <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians. Generic medicalrecord-keeping standards. London: RCP, 2007.C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013 273


ISBN 978 1 86016 512 2<strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians11 St Andrews PlaceRegent’s ParkLondon NW1 4LEwww.rcplondon.ac.ukSetting higher standards

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