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2 Specialties Diabetes and endocrinologystroke physicians, cardiologists, rheumatologists,emergency care teams, elderly care teams and every kindof inpatient hospital care for which people with diabetesare admitted. The need to involve such specialties isoften concurrent with the need to reconfigure themetabolic care plan.Both diabetes and endocrinology are heavily dependenton close collaboration with laboratories. This isparticularly the case for endocrinology where access tospecialist laboratory techniques may determine theability to deliver service. Endocrinology is alsodependent on a variety of sophisticated imagingtechniques requiring close collaboration with specialistradiologists. For the management of pituitary diseaseendocrinologists work in teams with neurosurgeons andradiotherapists; for thyroid and adrenal disorderspartnership with an endocrine surgical team is essential;for reproductive endocrinology it is necessary to workclosely with 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 of genetically based endocrine disorderssuch as CAH and multiple endocrine neoplasia willusually involve geneticists. The majority of 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 of 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 of 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 andwith ongoing audit of satisfaction and outcome.Regional centres deal with the rarer endocrineconditions and should be co-located with thelaboratory, imaging and surgical teams in order toprovide a seamless, comprehensive, safe andhigh-quality service.Maintaining and improving the quality of careThis work encompasses continuing professionaldevelopment (CPD), clinical governance, professionalself-regulation, education and training. For manyconsultants, at various times in their careers, it may alsoinclude research, management and providingprofessional advice. Management is a commoncomponent of 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 of primary care and communitystaff and those working 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 ofBritish Clinical Diabetologists (ABCD)www.diabetologists.org.uk Royal College of Physicians (RCP)www.rcplondon.ac.ukEndocrinology guidance and guidelines NICE guidance: technology appraisals for theuse of 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 of consultantsHow a consultant works in this specialtyMost consultants with a specialist interest in diabetesand endocrinology work in acute hospitals. TheyC○ Royal College of Physicians 2013 93
Consultant physicians working with patientscontribute substantially to provision of 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 inpatients.Most diabetes/endocrine consultants are also trained ingeneral medicine and take part in acute medicine ‘takes’on a rotational basis. A small number of consultantsmay deal with diabetes without endocrinology, and asomewhat larger number may be endocrine specialistsalone. There is an increasing number of diabetologistswith a community diabetes specialty.Inpatient workDiabetes is over-represented in hospital populations(about 17% of NHS beds are occupied by diabeticpatients), mostly due to complications such as coronaryartery disease or foot ulceration with infection.Treatment alterations and glycaemic control are doneon an outpatient basis by diabetes specialist nurses.Similarly, endocrine investigation and treatment arealmost entirely done without hospital admission.Diabetes/endocrine specialists therefore have anunusually high inpatient load of general medical, ratherthan specialty, patients. Diabetic foot disease (the mostcommonly admitted diabetes-related disorder) is alsoincreasingly managed on an outpatient basis with thesupport of multidisciplinary foot care teams. Inpatientconsultation work varies considerably depending on theco-specialty profile of the hospital. Because of the highprevalence of diabetes comorbidity among hospitalinpatients, 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 patientsas part of their endocrine clinic. Diabetes services: new patient consultations forpeople with diabetes are complex and requireapproximately 30 minutes of consultation time.Review diabetes patients require approximately20 minutes but may require more time. Additionaltime with other healthcare professionals (egspecialist nurses and dietitians) may also be needed. Endocrine services: new endocrine patients requireabout 30 minutes of consultation time and reviewpatients about 15 minutes. Complex reviews forpituitary patients or endocrine tumours, paediatrictransition or genetic consultations may take longerand arrangements for joint consultation with 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 of manypatients. 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% of the volume to their NHS colleagues.Quite frequently, the clinical contribution will berestricted to the specialty (eg no GIM, or onlyendocrinology). The academic component of 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. Examplesof integrated care in the specialty of 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 with primary care, includingcommunity diabetologists and GPwSIs in diabetes endocrine links with nuclear medicine (fortreatment of thyrotoxicosis): endocrine surgeons,geneticists and paediatricians joint management of patients with pituitary diseasewith pituitary surgeons, in pituitary centres transitional care (in both diabetes andendocrinology) for the efficient and sensitive movefrom paediatric to adult care.94 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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1 Physicians in the NHS todaycan be
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