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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 of 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 of trainees to trainingprogrammes is now running more smoothly, after thedebacle of the original implementation of ModernisingMedical Careers. The recommendations of 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, with local education and training boards. Itis important that the medical workforce and educationis planned with an overall national strategy and the RCPwill be closely involved in trying to ensure that any newarrangements do not lower the quality and effectivenessof medical training.In the last decade, the number of graduates from UKmedical schools has increased. There have been changesto immigration rules which have cut the numbers offoreign 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 offered in the past. However,there is now the potential, for the first time, for the UKto have a self-sufficient medical workforce, which offersthe opportunity of moving towards a fully consultantdeliveredspecialist service. However, to achieve this,numbers of medical staff and consultants must notbe cut.Continuing professional developmentUntil now consultants who are fellows or members ofthe RCP have been required to demonstrate thatannually they have achieved 50 hours of CPD activity,half of which must be external to their employing trust,and in a 5-year cycle of 250 hours, 25 of those creditsmust be non-clinical activity. It is likely that thisrequirement will remain, for revalidation, but that thedemonstration of having taken part will be expandedupon, by requirements to demonstrate reflection andappropriate change of practice in response to thelearning event.As part of the terms and conditions of service forconsultants, there is a national agreement whichstipulates a minimum time allowed for study andprofessional leave with 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 of CPD in order to keep up to dateand ensure ongoing quality of the medical workforce isessential for good patient care.RevalidationFollowing the Bristol and Shipman enquiries, 12 Sir LiamDonaldson, then chief medical officer in England,completed a review of medical regulation and publishedhisrecommendationsinthereport,Good doctors, saferpatients. 13 This was followed by the white paper, Trust,assurance and safety, 14 and by the report of the chiefmedical officer for England’s Working Group, Medicalrevalidation: principles and next steps. 15 Thesedocuments provided an outline for the developmentand implementation of revalidation for doctors.This is a mechanism to show that all doctors are upto date and fit to continue practising. The RCP isworking closely with the GMC, other colleges andpartners to develop the system of revalidation forphysicians. Revalidation is the responsibility of 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 of relicensureand specialist recertification. The proposed processhas also been streamlined, so that the minimumrequirements are to be five satisfactory annualappraisals, maintenance of CPD requirements,colleague and patient feedback, audit and qualityimprovement activity, and a review of critical incidents,complaints and compliments. The appraisal processitself has been strengthened and is being extensivelypiloted.C○ Royal College of Physicians 2013 5
Consultant physicians working with patientsChanging environmentHealthcare is now delivered within the context of arapidly changing society that is ageing andmulticultural, and has pockets of extreme affluence andpoverty. There are rising health inequalities, related tosocial inequalities. Society also needs to address diseasescaused as a result of 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, with our reports, education and attempts toinfluence the policy of the government.Our population is growing and getting older, with theaccumulation of chronic conditions and diseasesstrongly associated with older age – for example, risingincidences of cancer, dementia and frailty. Supportingcare for frail older people is a wider societal issue andprovision of 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 of olderpatients, and of patients with chronic conditions,obesity and damage caused by excess alcohol ingestion,means that all physicians must have the skills to dealwith these people, who may present with a wide varietyof presentations and illnesses.There is also a need for consultant physicians to beinvolved with patients who are on the surgical wards,offering expertise in the management of their medicalconditions which may deteriorate when they undergosurgery. 17 Consultant physicians and doctors in trainingare often called to deal with medical problems arising inpregnant women who are in the hospital. There is aneed for physicians who do not work directly withpregnant women to know more about the interactionbetween the conditions that they are treating andpregnancy. 18The RCP has published an analysis of 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 with solutions to makecare more patient-focused, deploy the workforcein a different way and deal with the risingworkload in the acute sector. This will reportduring 2013.The training and development of theconsultant physicianThe reality for many healthcare professionals hasinvolved coping with continuous change and risingworkload, with more complexity in the patients whomthey see. The ability to cope with repeatedreorganisations of healthcare, at a time of risingexpectations from patients and the public, needs to benurtured and supported, with flexibility of approachand a constant reference to the underlying values of theprofession and focus on the quality of care.Clinical practice is enabled and regulated withinframeworks that are common to all consultantphysicians in the UK: The GMC is ultimately responsible for registrationand regulation. Most physicians 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 of health set strategic objectivesresponding to the requirements of the governmentsin the devolved administrations. In addition, there are regulators and inspectors ofpractice, research and education, all of whichrequire attention and performance in their area ofactivity.Most medical consultants are employed by the NHS inhospital and community trusts, but the arrangementsdiffer in the four nations.They are all accredited specialists. Consultant physicianshold the Certificate of Completion of Training (CCT)previously awarded by the PMETB, now by the GMC.They are, with few exceptions, fellows or members ofthe Royal College of Physicians of London, Edinburghor Glasgow. Their training and development will havebeen supported in whole or part by one of these royalcolleges.At one time all consultant physicians were classed as‘general physician with a special interest’, for exampleconsultant physician with a special interest incardiology. However, as specialist subjects developedand expanded they reflected an increasingly complexbody of knowledge within individual disciplines. Thereare now an increasing number of individual specialistsocieties associated with the RCP. Now, some6 C○ Royal College of Physicians 2013
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